1. Veenema, Tener Goodwin PhD, MPH, MS, RN, FAAN
  2. Losinski, Sarah Lynn-Andrews MPH, BSN, RN
  3. Hilmi, Lisa M. MPH, BSN, RN


Examining the issues faced by U.S. health care organizations-and the policies to address them.


Article Content

Despite years of preparation, multiple presidential directives, and billions of dollars in federal funding, the outcomes of recent disasters suggest that many health care institutions are not prepared to handle unanticipated patient surges or other sudden operational challenges. The consequences of this are frightening: it means that the United States isn't prepared to protect its citizens from natural disasters, outbreaks of infectious diseases, or acts of bioterrorism.1-3 What is being done to change that? This article will present an overview of the current issues in disaster and public health preparedness facing U.S. health care institutions. It will address recent policy proposals and explore how these policies are relevant to nurses-particularly to those nurses working in hospitals.

Figure. Photo by Bil... - Click to enlarge in new window Photo by Bill Koplitz / FEMA.


Following a disaster, survival rates depend on health care facilities' ability to provide care under duress and to handle a sudden influx of large numbers of victims. Much depends on the staff, stuff (supplies, equipment), structure, and systems that are required to treat a significant increase in patients seeking medical and nursing care4; this may be problematic in many regions of the United States. Solutions to these challenges are elusive. Many will argue that EDs are already functioning in a disaster mode on a daily basis,5, 6 as they are often understaffed, underresourced, and overused.7 Yet this is part of the problem-when thrown into disaster mode, an already overburdened ED may be less flexible and less able to respond to emergency challenges.


Traditional hospital and clinical care standards may be impossible to maintain in the event of a major disaster such as a pandemic or a bioterrorism attack.8 In fact, it can be expected that standards of care will change. The Institute of Medicine (IOM) has defined crisis standards of care (CSC) as "a substantial change in the usual health care operations and the level of care it is possible to deliver [in a public health emergency,] justified by specific circumstances."9 It goes on to say that, during disasters, medical care must promote the use of limited resources to benefit the population as a whole.


In 2012, the aftermath of Hurricane Sandy demonstrated that large urban hospitals are vulnerable to the ravages of natural disasters. The heavy storm surge and extensive flooding resulted in widespread loss of electricity and the failure of heating, ventilation, and air conditioning capabilities. Despite valiant efforts by hospital clinicians and staff, patient safety was jeopardized. Staff were forced to allocate scarce medical resources, such as vaccinations and dialysis procedures, and administrators came to regret their early decisions to shelter in place as backup generators failed and patients were forced to evacuate through darkened stairwells.10 The emergency evacuation of two of Manhattan's landmark medical facilities-New York University Langone Medical Center evacuated 300 patients11 and Bellevue Hospital evacuated 725 patients12-evoked the tragic memory of the catastrophic loss of hospitals in New Orleans in 2005.13, 14 Glaring weaknesses in our systems were revealed, despite the proliferation of policies designed to enhance emergency preparedness following Hurricane Katrina.



Equally troubling is the lack of preparedness among health care providers. For example, one survey of bioterrorism coordinators and emergency managers for 31 hospitals near a major metropolitan area found that more than half the nurses lacked necessary disaster response training.15 Indeed, despite efforts to advance nurse readiness, many nurses lack the necessary knowledge, skills, and abilities to demonstrate clinical competence in the disaster health care arena.15 Yet recent disasters have shown that nurses need to shift their work paradigm from general daily care to a model that accommodates the sudden unanticipated surge in the demand for health care. This model may force them to make very difficult legal, ethical, and moral decisions; examples include triaging who gets care first and who does not get care at all, allocating limited numbers of ventilators, and deciding who has access to lifesaving medications. Here advance training and preparation is crucial. In the event of a disaster or large-scale public health emergency, health care facilities will need to have plans and resources in place to adequately protect patients' health and safety. Ideally, these will include a centralized structure for control (incident command system), a framework for the allocation of scarce resources, and effective adaptation of standards for crisis care.9, 16



In the United States, disaster preparedness and response is guided by an overlapping network of local, state, and federal laws and regulations. The "pillars" of the emergency response system, according to the IOM, are hospital and out-of-hospital care, and public health, emergency management, and public safety organizations. While separate, these organizations work with local, state, and federal authorities to ensure that CSC planning and response occurs. Yet despite that federal involvement is required in disaster response, the truth is that "all disasters are local": for the first 72 to 96 hours after an event, local public health departments and health care organizations are expected to remain independently functional (see Figure 1). Because disasters are very low-probability but very high-consequence events characterized by uncertainty and complexity, appropriate policies are needed and monitoring for compliance is required.17

Figure 1 - Click to enlarge in new window Overview of Local, State, and Federal Emergency ResponseDHS = Department of Homeland Security; EOC = emergency operations center; NRP = National Response Plan. Source: U.S. Department of Homeland Security.


Various government organizations have established guidelines, standards, or tools designed to help health care organizations manage operations during and after a disastrous event (see Disaster Preparedness Tools). In late 2013, the Centers for Medicare and Medicaid Services (CMS) proposed its "Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers."18 These requirements seek to establish regulatory consistency across more than 68,000 health care institutions including, but not limited to, large hospital chains, nursing homes, community health centers, home health agencies, dialysis centers, and psychiatric hospitals. They were created after an extensive review of federal and state guidelines, as well as standards set by the Joint Commission and the National Fire Protection Association (NFPA). Concluding that current requirements were inadequate, the CMS attempted to establish a much higher bar for hospitals to meet in order to be prepared for a disaster.18 The CMS requirements specifically state that participating providers will


* develop an emergency plan using an "all-hazards" approach, which prepares facilities for all types of potential disasters, including natural, biological, chemical, and radiologic events.


* develop and implement policies and procedures based on the organization's emergency plan and a risk assessment of potential hazards and deleterious outcomes. The risk assessment will identify potential vulnerabilities that can materialize during an emergency-for example, a power outage during a hurricane may cause equipment failure.


* develop and maintain a communications plan that complies with both federal and state law and also ensures coordination of patient care across all health care providers in an organization as well as with state and local public health departments and emergency systems.


* develop and maintain training programs-including annual trainings, drills, and exercises-or participate in an exercise that tests the plan.



Although many of these regulations are similar to those already established by the Joint Commission, this is the first time such comprehensive guidelines have been proposed for 17 unique categories of health care providers and suppliers, such as ambulatory surgical facilities, hospice centers, and all-inclusive care programs for the elderly. According to this proposal (and underscoring its importance), all health care facilities must comply with all applicable federal and state emergency preparedness requirements in order to participate in CMS programs and to receive CMS funding. The CMS has not yet finalized the ramifications of noncompliance with these requirements.


Initial concerns about the CMS proposal include underestimated projections of the burden and cost of compliance.19 Changes in current risk assessment, emergency planning development, training and testing, communication systems, and overall policies and procedures may prove costly. Smaller community hospitals may need to partner with larger hospitals to achieve their goals. Participating providers may need to tailor disaster plans to the specific risks of their setting and population. Shifts in health facility NFPA preparedness codes in the revised CMS regulations20 and ambiguity concerning the timeline of the provision of subsistence supplies (food, water, medical supplies, and medications) for staff and patients present additional challenges for nurses. Yet failure to address emergency preparedness guidelines could result in persistent low levels of preparedness, inadequate staffing, failure to sustain business continuity, and loss of revenue to the facility. Additionally, these policies affect disaster nursing scope of practice, standards of care, and, potentially, staff willingness and ability to meet clinical responsibilities during emergency events.21, 22



Unfortunately, there is a scarcity of literature on the validation and standardization of performance indicators for emergency preparedness in health care settings.23, 24 Few disaster drill performance metrics have been developed and tested with conclusive results.25-28 While performance indicators are important in measuring the effectiveness of current preparedness efforts, to date no single tool has been adopted by all health care facilities. The proposed CMS regulations further emphasize the need to establish performance indicator metrics to evaluate ongoing and future disaster preparedness activities. In an ideal world, when working toward organizational readiness, nurses could use both lessons learned and evidence-based policies and interventions (see What Nurses Can Do).

Box. What Nurses Can... - Click to enlarge in new window What Nurses Can Do

Disaster Preparedness Tools

Centers for Medicare and Medicaid Services


Emergency Preparedness Checklist


Institute of Medicine


Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response


Joint Commission


Requirements for Emergency Management Oversight


Office of the Assistant Secretary of Preparedness and Response, U.S. Department of Health and Human Services


Hospital Preparedness Program




1. Steinhardt B. Influenza pandemic: gaps in pandemic planning and preparedness need to be addressed. U.S. Government Accountability Office (GAO-09-909T). 2009 Jul 29. [Context Link]


2. Levi J, et al. Ready or not? Protecting the public's health from diseases, disasters, and bioterrorism. Trust for America's Health; 2012 Dec. Report series. [Context Link]


3. Levi J, et al. Outbreaks: protecting Americans from infectious diseases. Trust for America's Health; Robert Wood Johnson Foundation; 2013 Dec. Infectious Diseases Policy Report series. [Context Link]


4. Barbisch DF, Koenig KL. Understanding surge capacity: essential elements Acad Emerg Med. 2006;13(11):1098-102 [Context Link]


5. Kamal N, et al. Addressing emergency department overcrowding through a systems approach using big data research J Health Med Informat. 2014;5:148 [Context Link]


6. Maldin B, et al. Regional approaches to hospital preparedness Biosecur Bioterror. 2007;5(1):43-53 [Context Link]


7. American Hospital Association. The state of America's hospitals: taking the pulse [PowerPoint presentation]. 2005 Oct. [Context Link]


8. Rubinson L, et al. Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: recommendations of the Working Group on Emergency Mass Critical Care Crit Care Med. 2005;33(10):2393-403 [Context Link]


9. Hanfling D, et al. Committee on Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations; Board on Health Sciences Policy; Institute of Medicine Crisis standards of care: a systems framework for catastrophic disaster response. 2012 Washington, DC The National Academies Press [Context Link]


10. Adalja AA, et al. Absorbing citywide patient surge during Hurricane Sandy: a case study in accommodating multiple hospital evacuations Ann Emerg Med. 2014;64(1):66-73 [Context Link]


11. Kolker R. A hospital flatlines: inside the NYU Langone Medical Center evacuation New York. 2012 Nov 3. [Context Link]


12. Shapiro J, Mays J. Bellevue Hospital evacuated after two days on emergency generators. DNAinfo New York 2012 Oct 31. [Context Link]


13. Franco C, et al. Systemic collapse: medical care in the aftermath of Hurricane Katrina Biosecur Bioterror. 2006;4(2):135-46 [Context Link]


14. Powell T, et al. Emergency preparedness and public health: the lessons of Hurricane Sandy JAMA. 2012;308(24):2569-70 [Context Link]


15. Reilly M, Markenson DS. Education and training of hospital workers: who are essential personnel during a disaster? Prehosp Disaster Med. 2009;24(3):239-45 [Context Link]


16. Hanfling D, et al. eds. Committee on Crisis Standards of Care: a Toolkit for Indicators and Triggers, Board on Health Sciences Policy, Institute of Medicine of the National Academies Crisis standards of care: a toolkit for indicators and triggers. 2013 Washington, DC The National Academies Press http:/ [Context Link]


17. Handmer J, Dovers S The handbook of disaster and emergency policies and institutions. 2007 London Earthscan [Context Link]


18. Centers for Medicare and Medicaid Services. Medicare and Medicaid programs: emergency preparedness requirements for Medicare and Medicaid participating providers and suppliers. Federal Register 2013 Dec. [Context Link]


19. American Hospital Association. Re: CMS 3178-P, Medicare and Medicaid programs; emergency preparedness requirements for Medicare and Medicaid participating providers and suppliers; proposed rule, Dec. 27, 2013. 2014 Mar 28.[Context Link]


20. American Society for Healthcare Engineering. CMS proposes adoption of 2012 editions of two codes. Issue Brief 2014. 2014 Apr 14. [Context Link]


21. McHugh MD. Hospital nurse staffing and public health emergency preparedness: implications for policy Public Health Nurs. 2010;27(5):442-9 [Context Link]


22. Veenema TG Disaster nursing and emergency preparedness for chemical, biological, and radiological terrorism and other hazards. 20123rd ed. New York City Springer Publishing Company [Context Link]


23. McCarthy ML, et al. Consensus and tools needed to measure health care emergency management capabilities Disaster Med Public Health Prep. 2009;3(2 Suppl):S45-S51 [Context Link]


24. Asch SM, et al. A review of instruments assessing public health preparedness Public Health Rep. 2005;120(5):532-42 [Context Link]


25. Kaji AH, Lewis RJ. Assessment of the reliability of the Johns Hopkins/Agency for Healthcare Research and Quality hospital disaster drill evaluation tool Ann Emerg Med. 2008;52(3):204-10 e1-8. [Context Link]


26. Gryth D, et al. Evaluation of medical command and control using performance indicators in a full-scale, major aircraft accident exercise Prehosp Disaster Med. 2010;25(2):118-24 [Context Link]


27. Nilsson H, et al. Performance indicators for initial regional medical response to major incidents: a possible quality control tool Scand J Traum Resusc Emerg Med. 2012;20:81 [Context Link]


28. Stoto MA, Nelson CD, and the LAMPS Investigators. Measuring and assessing public health emergency preparedness: a methodological primer [white paper]. Boston: Harvard University School of Public Health; 2012 Sep. [Context Link]