Question

What are some considerations for skilled nursing facilities or rehabilitation hospitals with respect to their patient populations in the setting of a disaster?

Course: Medical Disaster Managerment

Answer 1

When disasters occur, communities expect public health agencies and medical practitioners to provide services and leadership.1 The adequacy of response to these critical public health events is largely determined by the extent to which disaster plans are comprehensive and are tailored to the population’s needs and resources. Rapid implementation of such integrated plans is essential both for treating potentially large numbers of injuries2,3 and for ensuring the safety of vulnerable populations, especially that of high-risk groups such as persons with disabilities, elderly individuals, and the chronically ill.4–9

Often, these vulnerable populations reside in nursing facilities, an increasingly important component of the US health care system. For instance, almost 2 million adults are admitted to the nation’s 16 800 nursing facilities each year.10,11 Moreover, 1 in 2 women and 1 in 3 men are expected to spend time in nursing facilities over the next several decades.12 These statistics reflect the rising prevalence of chronic disease among an aging population and the increased use of nursing facilities for skilled postacute care. Since the late 1980s, hospitals have discharged patients earlier, and nursing facilities have assumed a greater role in caring for these sicker, more medically complex patients.13,14

Despite their expanded role in serving vulnerable populations, nursing facilities often are overlooked as a health resource and generally are not incorporated into disaster-relief plans. In fact, some researchers have dismissed nursing facilities as irrelevant to hospital patient care after disasters.15 Because few studies have focused on nursing facilities’ responses to catastrophes, the role of nursing facilities during these events remains undefined. Furthermore, little is known about the stresses that nursing facilities undergo during a community crisis. Although some data exist on the medical and psychological sequelae of disasters for vulnerable populations,6,16–19 there is scant information on systemwide responses to hospitalized vulnerable populations or nursing facility residents.20 When nursing facilities are mentioned, the focus usually is on a single facility’s experiences or on a single problem such as evacuation. These reports indicate that the health care system’s response to this population may be problematic.21 For example, the general impression after Hurricane Andrew in 1992 was that Florida nursing facilities were ill-prepared to respond to the disaster.20,22,23

To help address this paucity of information, we surveyed Los Angeles County nursing facilities to learn about their experiences after the 1994 Northridge earthquake. Both the extent and the location of this disaster provided a unique opportunity for examining nursing facilities during community crisis. Despite the fact that California prepares for such events, the 6.7-magnitude quake produced widespread damage. Fifty-seven deaths (33 from trauma, 24 from sudden cardiac death) were attributed to the temblor, more than 900 patients were evacuated from damaged hospitals, and more than 9000 people were treated in emergency departments or hospitals.24 The event was so significant that Donna Shalala, then Secretary of Health and Human Services, activated the National Disaster Medical System and sent Disaster Medical Assistance Teams to the area. By examining nursing facilities’ responses to this crisis, we hoped to expand the data on how these facilities function after disasters, to identify problems they may experience, and to gain a better understanding of their potential role in the larger health service delivery system. Acquiring better information in this area is particularly important in light of the recent terrorist attacks in the United States and the increased focus on improving community disaster response.25

METHODS

Sampling Frame

We attempted to identify nursing facilities that were structurally damaged by the earthquake. We contacted the Los Angeles Building Inspector’s Office, the state and county Departments of Health Services, the state and county Offices of Emergency Services, and the Office of Statewide Health Planning and Development to determine whether these organizations had obtained any information on earthquake damage related to nursing facilities. We also contacted the Los Angeles Times, the leading Los Angeles newspaper, which provided extensive earthquake coverage. None of the public data collected by these groups after the earthquake included nursing facilities as a category or even listed such facilities as health facilities.

We matched Los Angeles Building Inspector’s Office maps outlining areas of commercial/residential damage with California health facility planning area (HFPA) maps to determine which HFPAs were affected by the earthquake. With this mapping process, we identified 7 HFPAs that experienced significant damage. We then used Office of Statewide Health Planning and Development data to identify nursing facilities located within these HFPAs. We determined that 144 nongovernment and government nursing facilities were located within the 7 affected areas.

We mailed a disaster response survey to the administrators of the 144 facilities that we had identified in the affected areas. The surveys were mailed in June 1994, 5 months after the January 17 earthquake. A cover letter encouraged administrators from both damaged and undamaged facilities to respond. This letter included endorsements from the California Association of Health Facilities and the California Association of Homes and Services for the Aging, 2 voluntary statewide organizations representing long-term care and nursing facilities. In August, all nonrespondents received a follow-up telephone call and mailing. Nursing facilities returned completed surveys between June and September 1994. No financial incentive was provided.

Survey Items

Our survey addressed 5 phases of disaster planning and management that have been identified in the public health literature: anticipation and prevention, alert and warning, immediate postevent, assistance and relief, and rehabilitation.26 We also incorporated feedback from members of a local nursing facility consortium. Specifically, the survey questions addressed nursing facilities’ disaster plans, structural damage sustained, postdisaster assistance contacts received, changes in admission patterns after the disaster, and problems experienced after the earthquake. The 5-month delay between the earthquake and the survey mailing allowed us also to query nursing facilities about rehabilitation after the acute recovery phase. We pilot tested the survey with administrators from 3 nursing facilities and used the pilot data to revise the survey. Although most questions were multiple-choice format, we included some open-ended questions to better elicit each facility’s experiences.

Structured Interviews

After mailing the surveys, we conducted separate structured interviews with 3 social workers who participated in discharge planning for different hospitals and with 3 social workers from different nursing facilities. We interviewed persons who were actively serving clients in the HFPAs at the time of the event and who were continuing to do so at the time of the interview. One social worker was from a damaged hospital that had evacuated patients, and 2 were from hospitals that continued to operate. Likewise, 1 nursing facility representative was from a facility that had closed because of damage, and 2 were from facilities that remained open.

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