Personal Disaster Preparedness of Dialysis Patients in North Carolina

Discussion

Our results indicate that dialysis patients in this study were largely unprepared for a disaster. This lack of preparation was independent of any demographic variable examined, including literacy, education, income level, race, gender, or age (P > 0.05), with the exception that PD patients are better prepared than hemodialysis patients (P = 0.01). Most have food and water for 3 days, but few have the remainder of the recommended items and even fewer still have all of the items collected in a bag or a kit for easy access, retrieval, and transport.

During a disaster of significant magnitude, one can shelter in place or evacuate. The essential preparedness difference is that one action requires resource stockpiling to survive a prolonged interval when society will not be effectively distributing goods, utilities, or civil services, whereas the other requires an individual to leave home without much forewarning. When dialysis patients shelter in place, they must be prepared to prolong the interval between dialysis treatments. This means having extra medicine and eating foods that adhere to the renal emergency diet. The Council on Renal Nutrition of Northern California created a 3-day Emergency Diet Plan, the goal of which is to prolong the interdialysis interval by limiting protein, potassium, sodium, and fluid intake more strictly than a regular renal diet. The diet provides 40 g of protein, 1500 mg of sodium, and 1500 mg of potassium daily (11). Stockpiling the proper foods to adhere to this diet is an easily attainable measure that can significantly prolong the interdialysis interval for an end-stage kidney disease (ESKD) patient (12). Only 57% of those questioned had knowledge of a renal emergency diet, and 63% replied that they have a 2-week supply of extra medicines.

Individuals should maintain personal stores of potassium-exchange resins along with instructions for use to mitigate hyperkalemia. After the 1995 Kobe earthquake (Japan) and the 1999 Marmara earthquake (Turkey), physicians successfully utilized potassium-binding resins and sorbitol to treat hyperkalemia and to extend interdialysis intervals (13,14). Prescriptions could be provided for potassium-binding resins with instruction to use them in the setting of disaster when dialysis access is limited. Patients and their families could be instructed to watch for early signs of hyperkalemia such as intestinal cramping, diarrhea, nausea, and vomiting or late signs including muscle weakness, flaccid paralysis, and cardiac arrhythmias (15). However, we found that too few subjects have any knowledge of the medication (13%) and even fewer have the medication at their homes (6%).

Evacuation during disaster poses many complicated logistical issues for ESKD patients. Hurricane Katrina demonstrated that most ESKD patients evacuate without prearranged dialysis services (16). During the Katrina evacuation, most patients did not wear an identification tag labeling them as a dialysis patient. In our study, only 15% had an identification tag. After the hurricane, hospitals and hemodialysis units that were not affected by the storm became inundated with evacuees, impeding their ability to deliver care for those in need (16). Preparedness measures could mitigate many of these threats. Having medical records, insurance information, and a list of medicines can expedite the process once a dialysis center is located. A plan of action including contact information for dialysis facilities near the homes of friends and family will facilitate getting to a clinic to receive treatment (4). In our study approximately 60% of respondents had not discussed the possibility of evacuation with a relative, had no knowledge of other dialysis centers, and did not have their medical records easily accessible to take with them on short notice.

The inability of cross-communication between electronic medical record systems is a ubiquitous problem within the health care system and affects the dialysis community's ability to respond to a disaster. If electronic medical record systems could cross-communicate, one could simply arrive at any facility with identification and a medical record number and would be able to safely and quickly receive treatment. Facilities could cooperate with one another to shunt patients to facilities operating below maximum capacity.

Twenty-seven peritoneal patients were enrolled in this study. All (100%) respondents had the phone number of a dialysis company, which is reflective of their knowledge of the process of ordering supplies. This would be useful in the event of forced evacuation. During Hurricanes Katrina, Rita, and Wilma, patients on PD fared better than those on hemodialysis (17). Accordingly, during these crises, most patients on PD who evacuated before the storm traveled with a 1-week supply of necessary items, and when they needed more supplies, they had the knowledge and experience to order them on their own. Also, a PD nurse was able to arrange emergency shipment of PD supplies in areas where transport had been restored from her location, thus helping with the provision of dialysis treatment from a remote location (18). However, the fact that <40% of enrolled PD patients had extra antibiotics or had notified local utilities of their special needs indicates that PD patients, like the rest of the dialysis patient population, are largely unprepared to shelter in place.

Mitigating the effects of disaster on dialysis patients will require local, regional, and national leadership. Local dialysis center leadership requires educating patients and providing resources to ameliorate logistical issues surrounding disaster preparedness. Developing a plan that is well rehearsed and communicated to patients and staff is key (19). The NKF recommends that dialysis centers should maintain a current list of patient contact information and transportation needs including alternative emergency contact information. Communication channels should be established between staff members, physicians, patients, and local agencies such as police, fire, electricity, and water companies. Utility companies should be notified of the dialysis facility's special needs (4). Additionally, facilities should know how many patients they could potentially dialyze in a day and have plans to acquire food-grade-water (water tankers) and electricity (generators) when local water and power services are interrupted (20). Most importantly, facilities must ensure that patients are educated for disaster preparedness.

Regional leadership by large dialysis organizations includes standardizing plans throughout their extensive network of facilities, rehearsing plans on a regional level, and regularly and frequently reviewing patient education materials. Large dialysis organizations should provide patients with listings of their facilities so that patients will have treatment options during evacuations. National leadership by organizations such as the American Society of Nephrology and the Department of Health and Human Services are critical to disaster mitigation. Despite the availability of online and printed educational disaster preparedness material, more efforts are required to ensure the message is being received. Disaster preparedness education should be part of a comprehensive patient safety plan by the American Society of Nephrology and similar organizations.