Table 4.

Additional ideas to improve emergency response, with a focus on kidney patientsa

ParameterPossible Approaches
Patient careRegion-wide dialysis patient database, populated with medical data, including dialysis prescription, medications, and comorbidities, entered before disaster with patient's consent (currently in preparation by the Louisiana Health Care Review)
Collaborative agreements between regional medical centers to transfer patients as needed
Track patients with infection, and monitor to ensure that appropriate precautions are taken in shelters and dialysis units
Expanded availability of alternative dialysis technologies: Sorbent-based dialysis machines, sterile hemodialysis solutions, and closed-loop dialysis machines
Oxygen source concentrators rather than tanks
Generous use of erythropoiesis-stimulating agents when a patient's customary dosage is unknown
Dialysis unit functionSatellite telephone, providing telephone and Internet access
Redundant communication modalities, ideally three or more [e.g., regular (analog) telephone, Blackberry-type device, satellite telephone, amateur radio]
Back-up electric power: Average-size unit with 16 to 20 dialysis machines and a water treatment system probably requires a 125-kW generator; formula available from ESRD Network 13 (17)
Free-standing dialysis facilities should identify partner facilities for mutual support
GPS coordinates disseminated to first responders and patients
Public and professional educationProvide kidney disease–focused emergency preparedness information to patients, first responders, nephrologists, dialysis facility personnel, and dialysis unit administrators
Provide patients with customized, detailed evacuation and care plans
Rehearse plans at all levels, and make changes where necessary
Evacuation and communicationsBefore imminent emergency, the dialysis facilities emergency response leaders should consider making a recommendation to state officials to issue mandatory evacuation order for dialysis patients
DIPP: Predesignated location along evacuation routes (highway rest stops, service stations, Wal-Mart, Home Depot, Lowe's, banks) where up-to-date, reliable information can be posted and regularly updated, including specific directions for dialysis patients
Information sources for dialysis patients posted on local television stations along with other emergency broadcast programming
During evacuation, patients encouraged to check-in via telephone or e-mail to ESRD network or LDO provider to ascertain location of functioning dialysis units, which would also facilitate dialysis unit planning for patient surge
Interoperable communications clearinghouse platform with a web portal available to first responders, providers, and dialysis staff; this would facilitate private communication about specific patients via telephone and secure communication network
Plan for school buses, rental buses and vans, and designated drivers to transport those without private vehicles
Designate media spokesperson for each dialysis unit and organization
Disasters involving major trauma and crush injury will require air transport to hospitals in nearby cities and states for surgical and nephrology care
Patient tracking and health recordsDeploy an EHR system with operability across the disaster theater; medical records could be created or updated by first responders or subsequent providers; this would facilitate evacuee tracking as they move around the disaster theater (a project under way within HHS)
Evacuee identification system, bar-coded, possibly linked to fingerprints, iris scans, or radiofrequency-implanted chips in selected patients; preregistration of selected patients by dialysis facilities
Data entry via personal digital assistants and laptop computers used by first responders, field hospitals, shelters, and dialysis units
Maintain and update medical data for dialysis patients (including medical history, medications, and dialysis prescription) in a local database that is overseen by the ESRD networks; at the time of an evacuation, transfer data into the HHS disaster electronic medical record system
First-respondersTriage, treat, and transport: Triage stations should treat if necessary and transport to perimeter zones as rapidly as possible to avoid congestion in the central zone
Improved field hospital assessment, with adequate laboratory facilities to measure patient chemistries that are relevant to dialysis patients
KMAT: Proposed teams to be run by the NDMS and modeled on the DMAT; under consideration are four regional teams (Northeast, Southeast, Gulf Coast, and Pacific Coast), each partnering with a DMAT for training and deployment; the KMAT would have dialysis capacity using sorbent dialyzers and other technologies, and the DMAT would provide general medical care and logistical support
CoordinationDesignate individuals to orchestrate the response to dialysis facility needs at the state EOC and federal JFO
Prearranged collaborative agreements among large academic nephrology programs, renal transplant programs, and ESRD networks to facilitate care of dialysis patients with multisystem illnesses, pediatric dialysis patients, and renal transplant patients
SheltersPredisaster designate particular shelters that will concentrate dialysis patients and are located near several dialysis units that are prepared to receive an influx of dialysis patients; coordinate with transportation resources; develop supply depots, either prestocked or stocked upon need from SNS
GPS coordinates disseminated to first responders and patients
Detailed and uniform triage protocols
Protocols for care of kidney patients, including plans for isolation of peritoneal dialysis patients during exchanges, infection control, and diet
VolunteersLocal volunteers recruited and organized before disaster, using volunteer service organizations
Pairing of dialysis units with local faith-based or service organizations to develop a plan for transportation and other volunteer services
Assessment of emergency responsePredisaster: Informatics tool to analyze available resources, including anticipated surge volume and surge capacity of dialysis units, shelters, hospitals, response teams, communications, and transportation
Postdisaster: Informatics tool to analyze response efforts, including systematic collection of comments from medical professionals and patient-level data (e.g., interdialytic intervals; use of emergency transportation, emergency rooms, and hospitals; and infectious and other complications); the goal is to provide efficacy data to aid future emergency response planning
  • a DMAT, disaster medical assistance team; EHR, electronic health record; EOC, emergency operations center; GPS, global positioning system; HHS, Department of Health and Human Services; JFO, joint field office; KMAT, kidney medical assistance team; LDO, large dialysis organization; SNS, Strategic National Stockpile.