Public Health Emergency Preparedness

4. Conclusions

This study can help fill gaps in our knowledge about the role nursing homes could play in larger local or regional preparedness efforts. In addition, the study reveals many concerns specific to nursing homes and the populations they serve that should be addressed if these facilities are expected to provide resources to the community during and after a public health emergency.

Based on our findings from the six focus groups, nursing homes have prepared for natural disasters but have given very little thought to bioterrorism. Facilities reported having disaster plans in place, some more comprehensive than others, and reviewing these plans with nursing staff at orientation and during regular in-service trainings. Disaster plans appeared to focus on the natural disasters most prevalent in a region (e.g., wild fires, earthquakes, floods, hurricanes). Only a few facilities reported including policies and procedures specific to bioterrorism in their disaster plans.

All the facilities we spoke with reported quarterly fire drills and annual or semi-annual disaster drills. These drills were held in accordance with State requirements, suggesting that States may need to require more comprehensive drills that address bioterrorism if this is deemed important. However, focus group participants stressed that, if States do develop new requirements related to bioterrorism, it will be important to provide resources, including guidance documents, training, staff, and money, to their facilities so they could develop viable plans.

Results from the focus groups also highlight the differing levels of local coordination of disaster planning across States. Two States initiated focus groups or forums to discuss local coordination to which nursing homes and other long-term care facilities were invited. Participants reported varying levels of success with these activities, but they indicate that some States are actively trying to involve nursing homes in coordination efforts. Other participants reported no success in trying to engage local emergency planning agencies in disaster planning.

Most participants lacked a basic understanding of State regulations that govern nursing homes during an emergency. While a few participants (mostly those directly engaged in the local government) were aware of bed licensure or staffing regulations in a state of emergency, most were not. This lack of knowledge suggests that State nursing home associations or other regulatory bodies may need to be more proactive in informing nursing home facilities of changes in regulations during an emergency.

Focus group participants expressed a wide range of needs, some of which were unique to nursing home facilities and some which would be problematic to a variety of health facilities. Participants voiced concerns about caring for special patient populations that require specialized equipment or nursing care during an emergency. In particular, participants were concerned about patients with Alzheimer's and other cognitive impairments. Many facilities caring for these patients have locked facilities with high-tech monitoring systems that could easily fail during power loss.

Participants also were concerned about the logistical difficulties involved in moving or evacuating patients with limited physical abilities. Focus group participants stressed the importance of maintaining a calm, routine environment to avoid undue stress on their elderly patients. Linked to these concerns about patient care were concerns about staffing. Participants were concerned about maintaining staffing levels since nursing staff would undoubtedly want to care for their own families or may have difficulty getting to work.

Several concerns raised by focus group participants may be of concern to the larger health care community. These include:

• Maintaining adequate pharmaceutical and medical supplies.
• The ability of generators to support an entire facility and the adequacy of fuel supplies.
• Feeding the resident population and keeping them adequately hydrated.

Most participants reported that pharmaceuticals and medical supplies are delivered on monthly cycles. Thus, the amount of time they could sustain their resident population on existing medical supplies is highly dependent on when the disaster occurred in relation to their last delivery. While all nursing home facilities represented have generators to provide back-up power, many participants were concerned that the generator would not be able to power the entire facility. Nursing home populations are particularly sensitive to heat and cold, so the environmental conditions regulated by generators are particularly important.

Finally, the focus group results suggest a number of potential roles nursing homes could play in the event of a public health emergency. Nearly all participants reported they could accept transferred residents back from area hospitals to free up bed space in those facilities. Most facilities acknowledged the possibility of receiving additional patients from the community and were willing to accommodate those patients if they could. In doing so, however, they had two major concerns: patient acuity and staffing.

Focus group participants agreed that their ability to accept transfers or patients from the community depended on the patient's level of acuity. They explained that many facilities specialize in caring for patients with certain conditions. Thus, one facility might be able to take a transferred ventilator patient while another could not. This suggests that area hospitals wanting to transfer patients would need to know what the nursing homes in their area were skilled in. Participants also stressed that they would need staff with the knowledge and expertise in providing care to higher acuity patients if they were to accept them.

Nursing homes could provide a variety of additional resources during an emergency, including basic medical care and short term shelter. Participants agreed that nursing staff had the skills to provide a certain level of medical care to outside community members. They suggested staff could provide vaccinations, basic first aid, or triage services. Many larger facilities felt they could use their facilities' community spaces, such as dining rooms and auditoriums, to provide short-term shelter. However, long-term storage of equipment and stockpiled drugs was considered an inappropriate use of facilities. Providing long-term storage would require nursing homes to take space designated for specific activities away from the resident population.

Focus groups are valuable in that they provide very detailed information about a small sample of nursing homes and have high face validity. However, because of the relatively small number of nursing homes we talked with, our data do not allow us to generalize these conclusions to all nursing homes in the United States. We can, however, conclude that nursing homes have special patient populations that require disaster plans that address the needs of their residents. Nursing homes can also provide valuable resources to their communities if they are included in local and regional disaster planning activities.

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References

CDC, 2004. National Nursing Home Survey: 2004 Facility Tables. Available online: http://www.cdc.gov/nchs/data/nnhsd/nursinghomefacilities2006.pdf.

Dosa DM, Samsonov ME, Nace DA. A pilot study investigating bioterrorism preparedness in area nursing homes. JAGS 2003;51(S4):S117.

Helget V, Smith PW. Bioterrorism preparedness: a survey of Nebraska health care institutions. Am J Infect Control 2002;30:46-8.

Institute of Medicine (IOM). Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System. FJ Manning and L Goldfrank (eds), Washington, DC: National Academy Press. 2002.

Maxwell JA. Qualitative Research Design, An Interactive Approach. Thousand Oaks, CA: Sage Publications. 1996.

Morgan DL and Krueger RA. The Focus Group Kit. Thousand Oaks, CA: Sage Publications. 1998.

Saliba D, Buchanan J, Kington RS. Function and response of nursing facilities during community disaster. Am J Public Health 2004;94(8):1436-41.

Spillman BC, Lubitz J. New estimates of lifetime nursing home use: have patterns of use changed? Medical Care 2002;40(10):965-75.

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AHRQ Publication No. 07-0029-1
Current as of May 2007