Natural disasters seem to be more and more common these days.
When I lived in California, we were often reminded to be prepared for an earthquake-related disaster. Sure enough, it happened while I was at the hospital.
I was working the night shift when one of the stronger earthquakes hit. We had practiced and reviewed our disaster plan several times so we knew what to do.
I was the charge nurse that night, and things ran smoothly with triaging the patients in case we needed to evacuate, collecting the disaster kits we had prepared, and being prepared to hand-ventilate babies who might need it. Luckily for us, there was no damage to the hospital. We did not have to move, and we did not lose power. The noise of alarms being triggered by air pressure loss and parents calling in non-stop to check on their babies were the most troublesome things we had to deal with (thankfully).
Healthcare disaster plans
Many recent disasters have been hurricane associated. There are now several reports in the literature of disaster-related events from Hurricane Katrina in New Orleans,1 Hurricane Sandy in New York,2 and undoubtedly, we will hear reports from hospitals and neonatal units in the Hurricanes Harvey and Irma paths.
As with many natural disasters, fire and flooding may follow. Staffing, communication, and food and water may all become issues depending on the extent to which the hospital is isolated, and the length of the isolation or need for evacuation.
More than one of these disaster reports noted that a disaster plan was in place but lacked key elements needed at the time of the disaster. Notably, in Hurricane Katrina, disaster plans were inadequate because the effects and extent of the storm were so much worse than anyone imagined it would be.
Disaster plan updates
While disaster plans are important, it is also important to review them periodically and simulate or practice how they might actually work.3 Even so, it is important to be able to improvise and be flexible in a disaster – things sometimes happen that could not be anticipated!
Orlando, Bernard, and Mathews1 present the experience of being in a New Orleans NICU during Hurricane Katrina. They point out the shortcomings of any disaster plan for such an unexpectedly severe storm (many of you reading this will remember that unplanned evacuations occurred after severe flooding).
They pointed out the importance of assessment skills taking the place of technology when power was not available, and when electronic monitors, infusion pumps, and ventilators no longer function. Observation skills honed in nursing school and for years afterward (but sometimes not utilized as much as they could be) become primary.
Assessment skills and action plans
Self-inflating bags: Our flow-inflating ventilation bags no longer work when pressurized gas is not available. Many of us are very comfortable using these, and check their functionality and presence at the beginning of every shift. But self-inflating bags must be readily available in case of a disaster. When infusion pumps don’t work, one must go back to setting IV infusions manually. How many of you remember how to do that?! I know I don’t, and I can’t even remember the last time I had to do it – probably in nursing school over 30 years ago! Often infants will be quickly weaned off IV fluids and feedings increased, if at all feasible.
Gravity feeding: In addition, many of us are used to using an electronic pump for feedings. Feedings can easily be given by gravity, although feeding tubes may need to be re-used, something certainly not recommended in routine care.
Hand pumping and cup feeding: When faced with a power outage, March of Dimes recommends that mothers hand pump, and infants are cup fed.4 While cup feeding continues to be of debatable value in preterm infants in general practice,5 it is recommended in low resource countries by the WHO and UNICEF6. During a disaster, we are all “low resource!”
Even the smallest babies can be fed via cup feeding, requiring simply that the paper cups be kept clean until used. Hand pumping and cup feeding negates the need for refrigeration and cleaning mechanical pumps and bottles, or use of gavage tubes that cannot be cleaned when a clean water supply is not available4. This practice, of course, demands that mothers are present with their infants. In some cases, this will be possible and many mothers may prefer this. However, as in the case of Hurricane Katrina, many families, mothers included, were already evacuated before the hospital was evacuated. This also presented communication problems – contacting parents who were moving from place to place, cell phones that were inoperable or battery depleted, and parents searching for infants who were no longer in the original hospital.
Institutional and personal preparedness
Both institutional and personal disaster preparedness are important.
When I was working during Hurricane Alicia in Galveston in 1983, I arrived at work completely naïve of what a hurricane could do or how long we would be at the hospital. Fortunately, many colleagues brought extra food, ample toiletries were available, and supplies lasted for the four days and nights we spent at the medical center.
Power was minimal after the storm, while the heat and humidity continued to be extreme. Any available power was used for medical equipment and air conditioners that were not functioning. We had to evacuate from the third floor to the second floor without power, while carrying warmers, oxygen tanks, and ventilators down flights of stairs.
The Hurricane Katrina experience in New Orleans1 described similar events but under far worse conditions, and for a prolonged period of time. Evacuations were eventually performed by helicopter or boat, requiring physical fitness of the working staff, and all without adequate sleep, or food or water, no doubt.
Institutional disaster plans should be developed and practiced, improved and practiced again.3 FEMA has recommendations for both personal and business/institutional disaster preparedness at www.fema.gov.
Family disaster preparation
To be prepared to work during a disaster, is it important that our own family disaster preparedness is in order. It is difficult, if not impossible, to work effectively if a nurse is worried about her own family, especially with no idea where they are or what has happened.
Don’t wait to prepare
Whether disaster planning for yourself and family, or for the institution, reviewing the plan frequently is a priority. Also important are making sure everyone involved knows what the plan is, that updates occur on a routine basis, and that the plan can be flexible during an actual disaster.
In the recent hurricanes, we have heard of folks who were cut off from food and medical supplies for days, if not weeks. This past hurricane season was a very active and devastating one, but it is important to remember that disasters can happen anywhere and for many different reasons. Don’t wait until the next hurricane season to get prepared. Or if you’ve previously prepared for a disaster, review it in relation to the current situation and check expiration dates regularly.
Good information and disaster preparedness checklists are available on multiple websites. A few that are specific to pregnancy and infants, or young children, are on the March of Dimes website at www.marchofdimes.org. Another helpful website for disaster preparedness is www.ready.gov.
Share your story with us! Has your hospital experienced an emergency? What worked well, and what would you change?
Looking for more from Sandra? Read her blog post on Skin-to-Skin or Kangaroo Mother Care.
- Orlando, S., Bernard, M. L., & Mathews, P. (2008). Neonatal nursing care issues following a natural disaster: lessons learned from the Katrina experience. The Journal of perinatal & neonatal nursing, 22(2), 147-153.
- Espiritu, M., Patil, U., Cruz, H., Gupta, A., Matterson, H., Kim, Y., … & Mally, P. (2014). Evacuation of a neonatal intensive care unit in a disaster: lessons from Hurricane Sandy. Pediatrics, 134(6), e1662-e1669.
- Femino, M., Young, S., & Smith, V. C. (2013). Hospital-Based Emergency Preparedness: Evacuation of the Neonatal Intensive Care Unit—the Smallest and Most Vulnerable Population. Pediatric emergency care, 29(1), 107-113.
- Flint, A., New, K., & Davies, M. W. (2016). Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed. The Cochrane Library.
- World Health Organization (WHO) Beyond Survival. Pan America Health Organization (PAHO)