Public Health Emergency Preparedness

3. Focus Group Results

The results of the six focus groups are organized into topic areas:

• Disaster preparedness and planning activities (3.1).
• Special needs identified by nursing home staff (3.2).
• Potential roles facilities could play during a disaster or other public health emergency (3.3).
• The influence of State regulations of preparedness and planning (3.4).

In addition, there is a section that explores additional topic areas brought up by focus group participants that were not specifically included in the protocol.

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3.1. Disaster Preparedness and Planning Activities

Nursing homes have plans in place for some public health emergencies but have not done planning specific to bioterrorism.

For the most part, participants reported their facilities had done planning for disasters or emergencies such as fires, major snow storms, earthquakes and hurricanes. However, only a couple participants reported planning activities specific to bioterrorism. Many participants acknowledged the importance of planning for bioterrorism or infectious disease outbreaks such as flu (and tended to categorize these two events together), but most admitted that it was "not on the radar screen," far down on the "list of priorities" or had "fallen off the table" in the years following 9/11. Several facilities reported developing new policies and procedures specific to anthrax.

For the most part, participants noted that their State regulatory and licensing agencies require they train staff for fires and other "disasters," but bioterrorism planning has never been required:

The State requires that we have disaster training and fire drills. We do drills for earthquake or power disruption... But terrorism, disasters, things like that have not been part of the required drills... have not been part of my planning.

We are required to have 2 disaster drills a year. We do take into account fires, power outages, earthquakes, tornadoes... We've not really done much with bioterrorism.

We don't really have anything set up that's formal for bioterrorism. We do have disaster preparedness but not specifically targeted to bioterrorism... fire, weather related, if we get to the point where we need to move residents out.

One participant noted that a comprehensive disaster plan, including bioterrorism preparedness, is "required as part of Joint Commission (JCAHO) accreditation."

For the few facilities that reported some level of bioterrorism or infectious disease planning, the level of planning varied greatly. One facility reported developing a plan in the immediate wake of 9/11 but the participant noted "I can't tell you a single thing that's in it or where it's located." Another participant reported using in-service trainings to review "signs and symptoms or what to be aware of" as well as what measures to take to protect residents, staff, and the facility if an infectious agent is identified. These trainings tended to be short (5 to 10 minutes in duration) and focused on flu, norovirus, and other common illnesses. Another participant who had been affiliated with the military before taking her position with the nursing home reported:

We've looked at our infection control and how we would handle a biological agent, how we would detect that. We have periodic training with the staff and try to go through each of the different areas. We have a rather... thick disaster manual. So at staff meetings we try to go through each of the sections and keep it in the forefront of their minds.

This was undoubtedly the most developed bioterrorism response among all nursing homes with which we spoke. Another facility had recently been involved in a HAZMAT scare when a contaminated patient was admitted to the attached hospital. This participant also reported a higher level of bioterrorism planning:

We have been involved with the bioterrorism process on the hospital side with the grant writing in terms of getting decontamination showers and some of the equipment... We recently spent time brushing up on bioterrorism and chemical effects.

All nursing homes conduct drills and staff trainings, but topics addressed in training are highly dependent on facility location.

All focus group participants reported conducting fire and disaster drills, as required by State licensing and regulatory agencies. Quarterly fire drills and semi-annual disaster drills appeared to be the norm among most facilities, although some facilities held more frequent disaster drills:

We do 12 hour shifts so we have 2 shifts; both do quarterly fire drills and semi-annual disaster drills... In addition, we do an in-service, once a year. We have a big fire and disaster in-service for all staff. Because when you look at just doing drills four times a year and disasters twice a year to two shifts, we may miss some of our employees.

[We] do fire drills, and once a quarter we have a disaster drill... whether it's an external disaster where we're taking in patients or an internal disaster where we have to ship patients out... it's done on all three shifts each quarter. It's a State requirement.

The types of disaster events that facilities focused on depended on the types of natural disasters prevalent in their location. Facilities in Southern California, Oregon, and Washington tended to focus on earthquake preparedness: "At least once a year we do a disaster drill... that is all internally focused. Usually we pretend it's something like an earthquake." One facility described an elaborate drill involving volunteers that act like patients and wear make up and tags that describe their medical condition:

At least once a year... we have the facility suffer an earthquake. We scatter people around with various identification items on them, and we have a command center that we've established though this training process... staff have to find people, triage them. We have a disaster at such time of the day that the shift changes.

Facilities in Southern California also reported preparing for wild fires while facilities in Washington and Oregon were more concerned with major snow storms and flooding. Participants in North Carolina were concerned with hurricanes and flooding while participants in Utah mentioned tornadoes and power outages. All facilities reported tailoring their disaster plans to these events.

Nearly all participants agreed that high staff turnover rates were a significant barrier to ensuring that staff are adequately trained for a disaster. In general, participants stressed that they go over disaster activities during orientation but expressed concern about whether this level of training is adequate. According to one participant, "we try to emphasize where to find information on what to do rather than what they should do". Other participants reported spending a significant amount of time addressing the details of the disaster plan with new staff:

I do an orientation myself with all the new employees that specifically deals with disaster and fire drill rules. We go over where the electrical shop is and if it's an earthquake we go over where the main gas line turn-off is (in case there's a rupture in the line) and the main line water cut-off. I cover that specifically with each new employee.

I think you just have to ensure that in your general orientation there is a safety portion and that people go and see where the gas the water and electricity shut-off areas are so they get the basics... You have to make sure that people know what to do.

Differing levels of local coordination around disaster planning are evident in different States.

A consistent theme across focus groups was the lack of involvement in local or State emergency planning activities by nursing home facilities. While several participants reported being involved in emergency or disaster planning meetings that took place immediately after 9/11, these meetings ended up being more information for nursing home administrators. According to one participant:

After 9/11... [our county] had a focus group looking at these issues... they were very focused on trying to organize within the county and included LTC in the focus but... you feel like you're a fly on the wall... there are hundreds of people there from major agencies, fire and police... I went to a couple meetings but it was more informational for me than giving input or trying to say 'we offer these services.'

One State had recently organized an emergency and disaster planning forum specifically for long-term care facilities that included a "task force of nursing homes." Focus group participants reported that representatives from that State asked for input on changes to rules and regulations that might be necessary in the event of an emergency. Participants in other States reported trying to coordinate with local or State emergency planning agencies with little success. One participant noted that she "attempted to get our county disaster preparedness representative involved with our facility" but was never able to. Another participant reported, "We haven't had much support from our local government. When you try to contact them to get somebody out to come to the building to help, there's really nothing or nobody available." Other focus group participants reported speaking with city or local community emergency planning agencies but did not find the interactions helpful:

We've been working with the city, local community services, and talked with them. They had some suggestions... we talked abut [our disaster plan] and reviewed it. They really wanted to focus on the fact that for the first 72 hours we're on our own. But we want to think longer term than that.

One participant pointed out that the local health departments in more rural areas of the State are "less effective" than those located in urban areas, making coordination even more difficult in these areas. Several participants suggested that this lack of coordination at the local level jeopardizes the utility of the disaster plans that nursing homes have put in place because they will unknowingly be relying on the same resources as other organizations in their communities. According to one participant, "I bet our disaster plan and the one of the organization next door are both relying on the same five ambulances."

Participants in one State were particularly adamant that nursing homes should not be included as a resource in local or regional disaster plans. According to one participant, "a nursing home historically is not part of any disaster plan... when you think of a disaster plan, the community number one resource: hospital. Nursing home is really not part of that equation." Facilities expressed a number of reasons why nursing homes are not suited to be a good resource. One participant pointed out that only nurses are available for patient care because "the doctor doesn't stay on site at the nursing home." Another participant stated that while nursing homes often have the largest facility in many communities, "most nursing homes would not have that space available" because they are "not designed to accept additional patients." Other facilities, such as schools, have large auditoriums and lunch rooms that could be used to help community members. Two participants started negotiations with local community services but eventually backed out because "the administrative decision of the facility was that we have other things on the fire that are priorities."

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3.2. Special Needs of Nursing Homes

Nursing homes have concerns about caring for special patient populations during an emergency.

Most focus group participants reported that one of their principal concerns in a disaster situation would be caring for the special populations in their facility with limited cognitive and/or physical abilities. Caring for residents with Alzheimer's disease or dementia during an emergency situation was of particular concern for many facilities. Participants stressed the importance of maintaining a calm, routine-based environment to avoid "losing this group to bad behaviors." One participant explained that these patients are especially vulnerable to the stress of a disaster. If pharmaceutical supplies ran out or were destroyed and these patients were without their medications, "it could be a very dangerous situation" because "without their meds [these patients] are extremely dangerous to themselves and others."

Residents with Alzheimer's and dementia are typically located in locked units where staff can monitor them very closely. Some facilities indicated that they have monitoring systems (e.g., WanderGuard®) in place to prevent residents with these conditions from wandering beyond supervised areas. In the case of a power outage, these systems would cease to function (as they require electricity), resulting in the need for additional staff to supervise and redirect these residents to keep them safe. Two participants remarked on redirection of wanderers:

[Our last stage Alzheimer's folks] would absolutely not know which way to go. You would have to have staff down there doing constant redirection... You would need to have concentrated staff down there.

We would try to assign somebody to stay by the main entrance door. So, if they did make their way down the elevator if it's working... Of course, in a power outage, it wouldn't be... But, if they did manage to go down the stairs, there would be somebody there stationed. That is the primary space that they would be able to get out. Even if the system went down, they would be caught.

When asked, not all of the facilities with these monitoring systems knew if their systems were hooked up to the generator. Even in cases where these systems are hooked up to the generator, concerns about the longevity of fuel supplies would be salient.

Focus group participants also addressed the increased time and attention that would need to be devoted to patients lacking the cognitive skills to understand and/or communicate about an emergency situation. Some facilities reported having formal procedures in place for handling such patients in an emergency. One participant explained that "just going around and letting them see you and touching them and saying 'It's okay, we've got it under control' is a very positive thing." However, this would require additional staff that may or may not be available.

While a few focus group participants briefly touched on the special needs of high-fall patients, concerns about caring for patients with limited physical abilities typically arose in the context of logistical difficulties involved in evacuating them. One participant shared her fear that the equipment (e.g., wheelchairs) needed to transport bed-bound and vegetative patients would be destroyed in the disaster. Another participant explained that his staff has been trained in performing "blanket and emergency carries" to handle circumstances such as these.

Concerns about staffing in an emergency were universal.

Adequacy of staffing impacts the ability of nursing homes both to successfully maintain normal operations for their current residents and to take on additional roles during an emergency. A number of focus group participants emphasized the importance of maintaining normal operations and standards of care to the best of their ability in an emergency. They acknowledged that this would be extremely difficult to achieve without additional assistance, much less with the reduced staff that they would likely have given the circumstances:

Our facility would be in dire need of assistance if not enough staff came in. In the event of a crisis, we would need more staff than normal.

Many facilities had clearly given substantial thought to how they would induce the staff needed to maintain normal operations to stay at or come to work. A few nursing homes said they had facilities available to care for staff member's families and children and would encourage staff to bring their families. Other facilities were prepared to provide nursing staff with rooms and food. One participants remarked "... if [staff] are unable to get home or there is a possibility that they won't be able to get back we do have them stay in the facility, give them a bed, they can stay right there." Some nursing homes mentioned having the capacity to care for children of staff that report to work. According to one participant:

One of the things I tell staff is, 'In the absence of communication, come on in. Bring your families... we will provide.'... Their homes may be destroyed. Maybe they didn't plan. Maybe they don't have water on-site... They know that they have a link. In us taking care of them, hopefully we will be able to continue providing care.

A number of nursing homes also had put plans in place to provide transportation to the facility for staff and their families. Several nursing homes reported having facility vehicles available to pick up staff members and transport them to the facility for work while one (urban) facility reported supplying staff with taxi vouchers:

In an emergency we'd go pick up people... use our service vehicles to do that... And we have had staff come in with their children and have something set up for their kids

We have a system in place where one of our maintenance people... will go pick up people. Either that or if he's unable to do it... we have taxi vouchers available.

Other potential solutions for staffing problems included: arranging to trade staff with other facilities, arranging for additional staff through local home health agencies and providing financial incentives to critical staff for working during a disaster. One participant explained his facility's strategy:

There's probably five or six facilities within 10 miles of ours. One of the things we are working on... is trading of staff. If some of their staff live closer to our facility and can't make it to theirs, 'Come to ours, bring your family to ours, and we will put you to work!' If some of our staff live closer to theirs, 'Go there. Bring your family there.' We are trying to make it as comfortable and easy as possible for the staff to come in.

In responding to questions about roles that their nursing homes could potentially play in an emergency, focus group participants emphasized that their ability to provide resources and services to the community would be highly dependent on staffing. According to one participant, "Even in a good situation (in which) you have full staff, there's not excess capacity to, to triage, to do many other things. Unless people came, you know, unless there were additional staff that would be mobilized... "

In addition to the concerns about staff adequacy during a time of crisis, some nursing homes mentioned that State regulations on the number of hours that clinical staff can work consecutively would be problematic in an emergency. Participants expressed differing levels of confidence that such regulations would be relaxed in a disaster.

Nursing homes are worried about running out of pharmaceutical and other medical supplies in a disaster.

Nursing homes typically receive medication deliveries on a cyclical basis. Monthly delivery cycles appeared to be the norm. Hence, the length of time that they could sustain on their existing medication supplies would be highly dependent on when the disaster occurred in relation to their last delivery. One participant explained, "If you're right at the end of the month and waiting for your medications to come in, oh boy, you're in trouble."

While most nursing homes mentioned keeping emergency medication supplies including antibiotics and narcotics on-hand, they explained that these supplies would not last long. Many participants described stockpiling medications as a desirable solution, but a number of issues associated with doing so were raised including rules against stockpiling, the high cost of obtaining large quantities of medication at a time, reimbursement issues, and concerns about security if the community became aware that they had such supplies. According to one participant, "We can't stockpile medications. We have to get rid of them. As much as I would like to for a disaster, we can't do it."

Participants stressed that the adequacy of medications and medical supplies must be taken into account when considering the potential roles that nursing homes might play in disasters. If, for example, nursing homes are asked to provide first aid or to care for patients transferred from acute care facilities, this will have a major impact on how long their limited supplies last. Many participants expressed concerns about the ramifications of running out of medications and medical supplies to care for their residents due to using them to provide care for people from the community or other facilities.

The adequacy of fuel supplies to power the generators is a major concern because power serves a number of important functions in these facilities.

All nursing homes reported having generators to provide back-up power in the event that their facilities lose electricity. When asked how long they would be able to power their generators without receiving additional fuel from outside sources, participants' responses ranged from less than a day to seven days. While nearly all nursing homes reported performing period checks of their generator's functioning, the generator often only powered a portion of the facility during the checks. This makes it difficult to predict the rate at which their fuel supplies would be exhausted if the whole facility were relying on the generator's power. Another source of anxiety is whether or not the generator is strong enough to handle the full load of the facility. One participant told the group that her staff had been warned at a seminar that:

When they run the generators on the full load for more than a day, most of them give out because they're not used to it.

One participant told the group that she is worried that the fuel they use during periodic checks of the generator's functioning will mean that they would not have enough left if an actual emergency occurred because they perform checks monthly, but only refuel once every three months.

Participants reported a variety of problems associated with generator failure. Power is needed to maintain acceptable environmental conditions in the facilities. Nursing homes may be forced to transfer their residents elsewhere if they are without heat or air conditioning for an extended period of time during certain parts of the year. One participant articulated the difficulties in deciding what temperature warrants undertaking the challenges associated with evacuation:

When you've got 150 residents and you're thinking about moving them all when the temperature gets to... That's a killer. We make it 86 degrees and we decide to move, but that's as high as it ever goes and everybody is comfortable... I have residents who think 90 is a good temperature.

Power is also necessary to keep some types of special equipment specific to this population going for a sustained period of time. For example, oxygen is used for some of the special beds in these facilities. In the absence of power, oxygen can be provided to patients that need it through portable oxygen tanks in lieu of the special beds. However, focus group participants stressed that portable oxygen only lasts a very limited time. One participant indicated that battery back-up is now available for "some, but not all" of the medical equipment.

Due to incontinence issues that are common with the geriatric population, laundry facilities are crucial. One participant pointed out that many facilities may not have even thought to ensure that their washing machines are hooked up to the generator. Without regular changes of soiled clothing and bed sheets, some patients would begin to experience skin breakdown and other such issues. Also, sanitation could become a problem.

Nursing homes are concerned about having sufficient food and water supplies.

Most nursing homes indicated that they could be self-sustaining on their existing food and water supplies for a period of about three days. While some nursing homes indicated that they store enough food and water to be self-sustaining for longer periods, a number of facilities indicated that their storage space is extremely limited. Given their space restrictions, storing extra supplies (above and beyond what the State requires) simply wouldn't be possible for them. To alleviate this problem, a few facilities distribute water and food supplies to residents for storage in their rooms.

When their existing supplies are depleted, these nursing homes will be in competition with the rest of the community to obtain more. Perceptions of whether a priority list for the replenishment of supplies exists and if so, where nursing homes would fall on such a priority list varied among focus group participants. According to one participant, "If a disaster is somewhat orderly, then it was stated that there might be some priority to supplies. But, probably not." Another participant indicated that, "We do have a three-day supply. Anything after that, we would be pretty much competing with everybody else who wanted to get water. But, I think we are kind of high on the list."

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