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Special Feature: Nephrology Roles and Responsibilities in Natural Disasters |
* Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland; Northwest Renal Network (ESRD Network 16), Seattle, Washington; Department of Nephrology, Ochsner Clinic, New Orleans, Louisiana; Renal Associates of Baton Rouge, Baton Rouge, Louisiana; || Nephrology Consultants of Northwest Ohio, Toledo, Ohio; ¶ Miller Dialysis Acadiana Region, Ville Platte, Louisiana; ** Department of Epidemiology, Tulane University, New Orleans, Louisiana; University of Alabama, Huntsville, AL; and Heartland Kidney Network (ESRD Network 12), Kansas City, Missouri
Address correspondence to: Dr. Jeffrey Kopp, Kidney Disease Section, NIDDK, 10 Center Drive, NIH, Bethesda, MD 20892-1268. Phone: 301-594-3403; Fax: 301-402-0014; E-mail: jbkopp{at}nih.gov
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Abstract |
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Introduction |
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In this article, we first review the recommendations that have been put forward by the Kidney Community Emergency Response Coalition (KCERC). Next, we consider in detail the process of disaster planning from the perspectives of kidney patients, dialysis facilities, and volunteer nephrology professionals who wish to contribute to disaster relief. The article will not provide a detailed prescription for nephrology disaster planning that will work for all facilities under all circumstances, but instead it will raise relevant issues and identify resources that can help in planning to ensure continuity of care for kidney patients.
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KCERC Recommendations |
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The objectives of the KCERC include the following: (1) To develop a strategic plan for national and local responses to address the needs of kidney patients in various disaster settings, (2) to specify clear roles and responsibilities for developing and implementing the strategic plan, and (3) to disseminate best practices and strategies to the state and local levels. In July 2006, KCERC completed phase 1 of its activities, consisting of the development and initial dissemination of tools and resources, as summarized in Table 1 (2). During phase 2, the KCERC will educate kidney patients; nephrology professionals; and local, state, and federal response workers about the tools and materials available. Phase 2 will also involve testing and refining the national kidney community response plan. Specific KCERC recommendations to help kidney patients, dialysis units, and emergency response planners are provided in Table 2. KCERC recognizes that disaster planning is a process and not an end in itself and will continue its planning and coordination activities. ESRD networks, clinicians, dialysis facilities, industry, and patient representatives will be at the forefront of implementation.
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Overview of Disaster Planning |
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Orderly predisaster evacuation of dialysis patients contributes greatly to ensuring continuity of medical care. Evacuees may travel on their own to stay with friends or in hotels, or they may travel by private car, public transportation, redeployed school buses, and other means to predesignated shelter sites. Community evacuation centers are categorized into two types: General population shelters and special-needs shelters. Special-needs shelters are designed to accommodate evacuees (and their family members) who require assistance with activities of daily living (e.g., patients with dementia and mobility limitations), specific medical needs that require intervention by health professionals (e.g., oxygen, glucose monitoring, dressing changes, medication administration), and infectious diseases that require protective equipment or isolation.
Community evacuation shelters may be staffed by local, state, and federal emergency response personnel, as well as by volunteers. The specific criteria for admitting patients to special-needs shelters are set by each state, and states differ as to whether dialysis patients are sent to general population shelters or special-needs shelters. During Hurricane Katrina, it became apparent that individuals were often reluctant to evacuate without their pets. In 2006, Congress passed the Pets Evacuation and Transportation Standards Act, which requires that most, if not all, evacuation shelters accept family pets and have veterinarians assigned to assist with their care. The food will vary among shelters; when Meals Ready to Eat are provided, patients with chronic kidney disease should be aware that the sodium content of each of these meals ranges from 1.7 to 2.3 g without the addition of the enclosed salt packet. Consumption of three Meals Ready to Eat will result in a very high daily sodium and potassium intake.
The special-needs shelter personnel play a key role in helping dialysis patients resume dialysis promptly. Upon arrival at evacuation shelters, dialysis patients should inform evacuation personnel of their need for regular dialysis. Likewise, emergency responders should be educated that dialysis is life sustaining; a document for this purpose has been prepared by the KCERC (3). Medical personnel should assess dialysis patients shortly after their shelter arrival, determining comorbidities and whether urgent dialysis is needed. Patients who have missed their regularly scheduled dialysis sessions are at particular risk and may report symptoms of congestive heart failure (shortness of breath) or hyperkalemia (muscle weakness). Ideally, laboratory testing will be available to determine serum potassium level; when laboratory analysis is unavailable, an alternative could be electrocardiography.
After Hurricane Katrina, some dialysis patients developed catheter-site infections as a result of prolonged immersion in contaminated water. Rapid diagnosis and treatment of these infections is important. When purulent drainage is present, patients should be isolated when they are residing in evacuation shelters, as recommended by the CDC (4). It remains to be determined whether the stringent infection control practices that are followed in dialysis units for patients with hepatitis B virus or antibiotic-resistant bacterial infections are applicable in shelters as well (5). Although some patients will not know their hepatitis B status, most dialysis patients will have this information or will know whether they receive dialysis in a segregated area of their regular dialysis unit. A number of states have laws that require patients whose hepatitis B status is unknown to undergo dialysis using infection control practices that are designed for patients who are hepatitis B antigen seropositive, with the exception of not needing isolation and not using a machine that is dedicated to patients who are hepatitis B antigen seropositive. For these patients, dialysis machines should be cleaned with bleach or equivalent solution after each treatment, and dialyzers should not be reused. Future studies will be required to determine whether there were increased hepatitis B seroconversions after Hurricane Katrina, as a consequence of dialyzing patients with unknown hepatitis B status. Early evacuation, improved access to medical records, and central coordination of evacuee referral to dialysis facilities may promote an appropriate distribution of patients with infectious complications so that patient needs are matched to facility resources.
A timeline to safety for dialysis patients is presented in Table 3, with factors affecting the timeline organized by timing relative to the disaster and level of intervention. Increased morbidity and mortality, as well as additional burden on the medical response effort, may occur when the interdialytic interval exceeds 5 to 10 d, although data from a disaster environment are limited. Providers should assist dialysis patients in creating individual timelines on the basis of particular needs, the local environment, and different kinds of emergencies.
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Recommendations for Kidney Patients |
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Dialysis patients and renal transplant patients should maintain a list of their medical problems, care providers, medications, and (when applicable) dialysis prescription. When these patients evacuate, they should bring this list and their medications and (when applicable) diabetic testing supplies. Dialysis patients should be familiar with the emergency renal diet (7). It is advisable to have at least a 2-wk supply of food for emergency use. After Hurricane Katrina, a number of patients who were trapped in New Orleans reported adhering to the emergency diet; that may well have saved their lives, as they waited days for their next dialysis treatment. Patients with diabetes should avoid the use of products with sugar, unless they become hypoglycemic. If patients find themselves stranded without provisions, however, dietary adherence may not be possible. Instead, patients will have to avail themselves of the disaster organization relief rations provided to them.
Americans are encouraged by the government to prepare for disasters by developing an emergency provision pack that contains food, clothing, and basic toiletries and can be carried in the event of evacuation. An example of such a pack is provided by The Missouri Department of Health and Senior Services "Ready in 3" initiative (9). The ESRD networks offer educational resources for patients on a variety of topics ranging from disaster planning to coping with chronic illness (6). Finally, patients who customarily adhere to their dialysis prescription, including diet, fluids, and medication, will be in optimal shape to survive in an emergency situation.
Patients should be made aware of a useful resource that allows them to maintain contact with families and friends. In July 2006, the American Red Cross launched the Safe and Well List, which is a web-based tool that allows individuals to exchange welfare information with family members and friends in the aftermath of a disaster (10). The site allows individuals to select standard messages indicating that they are safe and well, and family and friends can search the web site using the individual's name and telephone number or name and complete address.
During the Disaster: Assessing Needs, Finding Resources, and Maintaining Homeostasis
Physical factors (overall health, functional status) and psychologic factors (degree of self-advocacy and personality type, such as introvert/extrovert, reactive/proactive) will influence how a patient responds to the disaster environment. Martin-Diaz et al. (11) measured indicators such as physical fitness, feelings, daily activities, social activities, change in health, overall health, and pain and found that the "process of psychologic adaptation to problems deriving from dialysis is satisfactory." Perhaps the use of this evaluation tool could find application in evaluating dialysis patients who are involved in a disaster.
Dialysis is stressful for many patients under normal circumstances; dialysis in the chaotic disaster environment may contribute additional stress. After Hurricane Katrina, patients relocated several times as evacuation shelters changed; therefore, patients had to undergo dialysis at different centers with unfamiliar staff. In this setting, continuity of care is enhanced when medical and dialysis treatment records are readily available.
Medical staff, in the shelters and the dialysis units, can foster the patient's emotional well-being by allowing each patient time to talk about their feelings and by stressing these points:
Resolution Stage
A patient in a temporary shelter may experience a variety of emotions, ranging from relief to anxiety, depression, and anger. Patients should be assessed for signs and symptoms of posttraumatic stress syndrome (insomnia, flashbacks, and depression). Silove et al. (12) found that "acute traumatic stress may be a normative response to life threat which tends to subside once conditions of safety are established. At the same time, there is a residual minority of survivors who will continue to experience chronic post-traumatic stress disorder (PTSD) and their needs can be easily overlooked." Approximately 20% of Hurricane Katrina survivors had symptoms consistent with PTSD when evaluated 6 mo after the storm (13). Similar data specific for shelter evacuees or for dialysis patients are not currently available. Medical providers should be aware that patients will probably still be mentally processing many losses: The death of loved ones, absent friends and relatives, pets left behind, loss of property, and financial losses. Regular meetings with the renal social worker at the dialysis facility could be very beneficial in assessing psychological adjustment. Additional professional counseling might be indicated to assist the patient with any long-term effects that result from the disaster experience.
In conclusion, although the external situation may be outside of their control, the way in which individuals react to a disaster and its aftermath is determined largely by their psychological make-up. A multidisciplinary approach to patient care will be required to assist patients in adjusting to each phase of the disaster and its response.
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Dialysis Facilities: Preparation and Response |
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 TopAbstractIntroductionKCERC RecommendationsOverview of Disaster PlanningRecommendations for Kidney... Dialysis Facilities: Preparation... Volunteer Staffing: Physicians,...ConclusionsDisclosuresReferences |
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Planning begins with a local and regional environmental scan to determine what events are particularly likely to occur (15). What type of damage could the facility sustain? What can be done to keep the facility functional? What can be done to minimize the impact on facility operations? If, for instance, the facility is located in a flood-prone area, then are the supplies high enough off the floor to maintain their sterility? In an earthquake area, are the shelves, televisions, and machines secured? Management should have blueprints of the facility and know where all shut-off valves for utilities are located.
Education and training for both patients and staff also fall under the federal mandate. Patient training includes frequent drills for hand-cranking blood circulation, clamping and cutting blood lines to disconnect patients, self-protection during an event, and knowledge of the evacuation procedure. Patients should be given written materials for a 3-day emergency diet and contact information for the facility and their nephrologist. Staff should attend mandatory annual reviews, conduct patient teaching, and document for each patient the ability level to participate in emergency preparedness activities. Facilities should document that training and drills were conducted and evaluated. A continuous quality assurance process should be in place for assessment and improvement.
A plan for the protection of patient medical records is crucial: When a disaster occurs, access to patient information will provide for safer treatments and better informed staff. LDO generally have computerized medical records and can access patient records from any location. Other dialysis units may not have electronic medical records systems and may lack that capability. All facilities should maintain off-site copies of the following: A comprehensive list of all patients, the CMS 2728 Medical Evidence Forms, the dialysis prescription, and care plan for each patient. These documents should be stored in a secure location within the dialysis unit, such as a fireproof and/or waterproof box; should be easily accessible when evacuating; and should be updated at regular intervals. Facility medical and financial records should be backed up on a regular basis and stored at a secure off-site location.
An affiliation agreement with another dialysis unit prepares for the contingency that a dialysis facility becomes nonoperational and helps to ensure continuity of care for dialysis patients. Choosing a nearby facility as the back-up simplifies transportation issues, but if an event is regional, then the affiliate may also be affected. Ideally, each dialysis facility would develop affiliation agreements with both local and regional partners. Similarly, the ESRD networks are developing a back-up system whereby each network would be paired with a second network. This approach is intended to facilitate the restoration of administrative services to dialysis patients and providers.
ESRD care is delivered within the context of larger medical and social communities. Dialysis facility managers should communicate with local, county, and state emergency management organizations to contribute to the development of the community disaster plan. One critical lesson learned from the 2005 hurricanes was that emergency organizations were not aware of the special needs of dialysis and transplant patients, and this delayed timely assistance to this vulnerable population. Dialysis facilities should ensure that projected security needs are addressed in the community disaster plan, with specific plans for assistance from police, the National Guard, and other assets.
Disaster Response
Disaster response for a dialysis facility consists of a sequence of events. The senior individual present should activate the dialysis facility's emergency response plan. If a determination is made that immediate evacuation is indicated, then authorities are notified by a call to 911, patients and staff are evacuated from the building, evacuee names are listed, and the emergency box is retrieved and carried out. Next, a facility emergency command center is activated. The emergency plan should indicate possible locations, with alternates, and staff assignments, although flexibility in execution will likely be required. The ESRD networks, as part of their disaster planning process, require each dialysis facility to provide contact information for two emergency staff from each facility, including a work telephone number and with two alternative means of contact.
Communication, for both sending and receiving information, is critical to effective disaster response efforts. Standard methods, including landline phones and many mobile devices, may be inoperative during disasters. Most mobile communication devices rely on frequency modulation (FM) radio frequencies above 30 MHz (including very high frequency and ultrahigh frequency bands) to provide line-of-sight communication between the hand-held device and a relay station. Typical devices that use this approach include mobile (cellular) phones, Blackberry-type handheld devices, digital pagers, and communication via vehicle-mounted dishes. Most satellite telephones also use a ground station to communicate with the satellite. In a disaster, these relay stations may be rendered inoperative or overwhelmed with an extraordinary volume of calls. (Telephone networks are generally designed to provide 15% capacity, assuming that most subscribers will not be using their phones at the same time. In an emergency situation, the 15% threshold is typically exceeded.) In the setting of a functional but overloaded relay station, Internet communication that can wait for transmission may work better than telephones that require immediate access to the network. Tracking and personal alert systems that are widely used as proprietary devices by home health agencies and emergency transportation services usually rely on local telephone or relay tower service; these systems also proved to be unreliable after Hurricane Katrina, when the communications infrastructure was damaged.
Bidirectional satellite service provides a good alternative to communication systems that require relay stations. These satellite systems support reliable disaster data transmission that may be invaluable for real-time response, including patient tracking mechanisms and patient data retrieval. If the broadband service capabilities allow, then voice and video applications may also be supported. Satellite systems are widely used by the military, border patrol, emergency responders, and large businesses and are now available for dialysis facilities, shelters, hospitals, and others. These systems consist of fixed or mobile platforms (some with all-in-one suitcases) with service plan options of monthly or per-transmission fees. Another alternative is ham radio, which also uses frequencies above 30 MHz; dialysis units might be able to identify a local ham radio operator who is willing to assist in an emergency. A possible resource is the American Radio Relay League, representing radio amateurs (http://www.arrl.org). In the absence of functioning electronic communication devices, a dialysis unit may find itself communicating by sending staff members or volunteers to deliver critical messages in person.
An intriguing approach to maintaining contact between patients and dialysis facility staff involves global positioning system (GPS) devices in cell phones. GPS receivers are present in an estimated 100 million cell phones that are in use in the United States, as a result of federal law intended to help first responders locate individuals. These systems can provide a location to within 100 meters, although function may be compromised when the phone is located indoors or in densely populated cities. A free application, Mologogo (http://www.mologogo.com), allows users of certain cell phones and Blackberry-type devices to determine their location. A private network can be set up on the Mologogo web site to map the position of software-equipped phones in a particular group, such as a dialysis facilities’ patients. Other companies provide cell phone users with GPS capability, but the phones cannot be accessed by Mologogo software; one hopes that this might change in the future, perhaps with encouragement from the disaster response community. This system could be readily adopted by a dialysis unit to track the movements of its patients (and perhaps staff) in the aftermath of a disaster and direct first responders to transport those in need. Practical issues in deploying a tracking system that must be addressed include privacy issues (e.g., ensuring that tracking begins only after an emergency is declared) and the need for the cell phones to remain powered and in use during an emergency (when cell phones are often unreliable). If deployed, then this approach might be suitable for particular patients but not be feasible or desirable for all patients.
After a disaster, a status report should be made to the facility's management and medical director and to the KCERC web site and daily conference call. One staff member should be assigned to monitor the CMS web site for emergency regulatory notices, such as those that pertain to starting up emergency dialysis facilities or changes in Health Insurance Portability and Accountability Act requirements. If the facility is closed (defined as not operational for dialysis, according to KCERC criteria), then patients and staff must be notified. If phone lines are not operational, then a public service announcement may be the best option. If the dialysis facility has a web site and Internet access is available, then information for patients and staff may be posted.
If the dialysis unit is open, operations may not be routine. Patients may arrive anxious, out of medication for days, with new illnesses, and in dire need of dialysis. New patients may transfer from dialysis units that have closed. The medical director will need to be available to provide emergency dialysis orders and refill prescriptions. Some staff may be absent, and alternate staff may need to be identified. Sources of staff include affiliated dialysis units throughout the country, local dialysis units, volunteer staff (including those who are on a roster that is maintained by the American Nephrology Nurses Association (http://www.kidney.org/help), and the National Disaster Medical System (NDMS). Water contamination is a threat, and alternative water sources (e.g., tanker trucks) may be required. Source water should be tested more frequently for endotoxin than the Association for the Advancement of Medical Instrumentation standards require. CDC guidelines suggest testing for chlorine more frequently than usual when water service returns, because chlorine levels are likely to fluctuate after restoration of water supply (16). The duration of this frequent chlorine analysis will depend on local circumstances and will be guided by the pattern of results obtained.
If a dialysis facility is closed, then a preselected affiliated dialysis facility may be available. This arrangement works best in a localized disaster. The staff of the two units can work closely together to ensure continuity of care. Patient medical information from the emergency box should be made available to the alternate facility. If both the closed facility and the alternate facility are associated with an LDO, then patient information should be readily available from the computer database. When a dialysis facility notifies the relevant ESRD network that it has closed, the network enters that information onto a national web site. When an affected patient presents to a different dialysis facility, patient data are sent to the Standard Information Management System. In this national database, the patient record is coded as a transfer with a reason (e.g., Hurricane Katrina). Because the alternate facility will likely experience a dramatic increase in patient load, patient schedules and shortened prescription durations may be modified. Throughout this process, psychological stress will manifest in a multitude of ways. The dialysis facility emergency response plan should include stress management approaches for patients and staff to help prevent PTSD.
Recovery from Disaster
Once the patients’ needs have been met and the immediate threat of personal injury has passed, a thorough damage assessment of the facility should be initiated using a professional inspector, working with the facility's insurance carrier. This assessment should include inspection and testing of utilities. Damaged supplies and equipment should be removed and replaced. When a closed facility is reopened, staff and patients must be notified. Patients and staff may suffer from PTSD, which may manifest as depression, acting out, and missed treatments or shifts. Re-establishing the normal routine may take weeks to months.
In conclusion, we cannot control where or when a disaster will occur, but we can and must develop comprehensive plans. Dialysis providers have a fiduciary role in making the needs of kidney patients known to the broader medical and social communities and can fulfill this role by getting involved in local, state, and national emergency preparedness planning.
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Volunteer Staffing: Physicians, Nephrology Nurses, and Dialysis Technicians |
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TopAbstractIntroductionKCERC RecommendationsOverview of Disaster PlanningRecommendations for Kidney...Dialysis Facilities: Preparation...Volunteer Staffing: Physicians,...ConclusionsDisclosuresReferences |
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The NDMS is a section within the Department of Health and Human Services. The NDMS is responsible for supporting federal agencies in the management and coordination of the federal medical response to major emergencies and to federally declared disasters, including natural disasters, technological disasters, major transportation accidents, and acts of terrorism including weapons of mass destruction events. The NDMS meets these needs in part by supporting Disaster Medical Assistance Teams. The NDMS also maintains a roster of individuals with specialized skills, including trauma care, burn care, and pediatric care. In response to an initiative by the KCERC, the NDMS has agreed to include on this roster nephrology professionals, including nephrologists, dialysis nurses, and dialysis technicians. The specific function of these nephrology personnel will be to provide staff augmentation for existing dialysis facilities. Interested professionals may submit applications to be hired as intermittent federal employees; the application process typically takes several months. Information about the NDMS program for nephrology professionals is available at the KCERC web site (Table 5).
Dialysis units that experience staffing shortages in the context of a federally recognized emergency should contact local emergency personnel, who would contact the state emergency operations center and then the federal joint field office (JFO). If JFO personnel make a determination of need, then they will make a specific mission assignment to the NDMS to provide dialysis staff augmentation. It may also be possible to request NDMS support by participating in the KCERC daily coordination phone call, because JFO personnel are expected to be on the call. NDMS would then contact selected personnel on the roster and ask whether they are willing to serve. Individuals would then be activated as temporary federal employees. A typical deployment duration is 2 wk, because shorter deployments are difficult to accommodate in a disaster environment. For family or other emergencies, an early return home is possible. NDMS personnel are compensated during their period of active service according to their assigned civil service pay grade and travel to the disaster area on government travel orders. NDMS professionals must be US citizens and must hold a current professional license in any state or the District of Columbia, which allows practice as federal employees in any US state or territory. NDMS personnel when deployed are covered by the Federal Tort Claims Act, which provides for government defense against any malpractice claims.
Living conditions in a disaster environment and surrounding area are likely to vary considerably. Some response personnel will be lodged in hotels and eat in restaurants. Others will live under austere conditions, staying in a field tent that holds 50 or more individuals, eating in a mess tent, showering in a communal shower facility, and using latrines. In general, assignment notification will be made 24 to 48 h before deployment; therefore the necessary equipment and supplies should be assembled in advance. We believe that this system has the capacity to save lives and improve care for vulnerable dialysis patients in the event of a disaster. From a personal standpoint, the system provides an opportunity to serve in a time of national crisis and may represent a truly life-enhancing experience for the volunteer.
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Conclusions |
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We close with a few critical points for the kidney disease community (Table 6):
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Disclosures |
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Acknowledgments |
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We appreciate the dedication and efforts of more than 80 participants in the KCERC. This work includes both the recommendations of the KCERC as a whole (summarized in Tables 1 and 2) and additional opinions and recommendations that are those of the KCERC Physician Task Force. This work was supported in part by the Intramural Research Program of the NIDDK, NIH. We thank the following individuals for critical review of the manuscript and for providing many critical insights: Sharon Adler, MD, Harbor-UCLA Medical Center; CDR Michelle Braun, CRNP, NIDDK, NIH, USPHS; Demetra Denmon, RN, CMS; Glenda Harbert, RN, ESRD Network 14; CDR Sarah Linde-Feucht, MD, FDA, USPHS; Lee Hamm, MD, Tulane University Hospital and Clinic; Robert Star, MD, NIDDK, NIH; RADM Bob Williams, Office of the Surgeon General, USPHS.
In particular, we acknowledge that many ideas presented here emerged from experiences and suggestions of kidney patients. Finally, the we express admiration for the courage, fortitude, and resilience demonstrated by countless area residents, care providers, and emergency response personnel during the 2005 hurricane season.
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Footnotes |
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The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government. The authors assume full responsibility for the accuracy and completeness of the ideas presented.
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