objectives - society of critical care medicine | sccm

O b j e c t i v e s��■ Describe the most likely settings from which affected adults or children will seek care in shelters during disasters.

��■ Identify chronic and acute conditions for which advanced coordination is required to ensure that necessary infrastructure and medical equipment will be in place in case of a disaster.

��■ Discuss specific care that shelters must be prepared to provide to patients with severe chronic conditions and those with implanted devices.

��■ Cite examples of community plans for developing unique shelters for people with special healthcare needs, and explain how the plans incorporate incoming federal and state resources.

C a s e S t u d yA loud blast is heard and the earth begins to roll. A legally blind, 80-year-old female with chronic congestive heart failure, macular degeneration, and non-insulin-dependent diabetes mellitus who lives alone and uses a walker does not know what to do. Neighbors find the woman, but due to evacuation orders from authorities (secondary to cracks in walls and risks of fire and flood), she is taken to a shelter in a local high school. She has no relatives in the area and does not recall her medications or their dosages.

- What types of special health care may be needed by people who seek refuge in shelters?

- What resources may be necessary for the frail, the elderly, and others with complex medical conditions?

- When is it inappropriate to admit a person with special healthcare needs to a mass care shelter?

C h a p t e r 1 1 :

Delivering Acute cAre to chronicAlly ill ADults in shelters

Asha Devereaux, MD, MPH Suzanne M. Burns MSN, RRT, ACNP, CCRN, FCCM

Robert Gougelet, MD

F u n d a m e n t a l D i s a s t e r M a n a g e m e n t

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I . I n t r O d u C t I O nGiven advances in technology and healthcare infrastructure, Americans, including those with disabilities, are living to an average age of 73 to 76 years, independently and away from family members to assist them. Recent disasters have shown that citizens who have functional or medical deficits or are frail or elderly, reliant on medical devices, or socially or economically disadvantaged require a high degree of assistance and are more likely to require hospitalization during and following a disaster (1). Meeting their medical needs during a disaster requires planning, preparation, and support. Every healthcare worker volunteering to assist in a shelter during a disaster will be faced with unexpected and unanticipated medical situations.

As noted in Chapter 2, critical care providers must be cognizant of the need to incorporate the unique critical/acute care requirements of special populations into their hospital’s and their community’s overall intensive care unit (ICU) and emergency preparedness plans. By preparing in advance to meet the potential acute and maintenance needs of specific vulnerable populations, critical care providers will gain greater flexibility in managing the increased demands of a mass casualty incident. If victims’ existing medical conditions are not addressed in local shelters, many will come to the hospital for their acute care needs, further straining available resources.

I I . M e e t I n g t h e n e e d S O f A d u l t S W I t h C h r O n I C I l l n e S S e S

A . C h a r a c t e r i s t i c s o f A d u l t s l i k e l y t o n e e d t r e a t m e n t i n S h e l t e r s

Recent disasters in the United States (hurricanes, floods, and fires) have shown that large-scale, rapid evacuations may be necessary in order to save lives. A September 2005 survey of evacuees from Hurricanes Katrina and Rita reported that 41% had a history of at least 1 chronic disease, such as heart disease, hypertension, diabetes, asthma or lung disease, physical disability, or cancer (2). A more extensive review by the Centers for Disease Control and Prevention and the Louisiana Department of Public Health showed that 25% of visits to emergency treatment facilities were primarily due to exacerbation of chronic illnesses and that the greatest proportion of that group was over the age of 60. Among 17,354 visits, nearly one-third required hospitalization (1). Healthcare facilities affected by the disaster experienced a surge of patients who required care that lasted months beyond the actual event. This demand was often met in shelters or alternative care sites adjacent to a medical center, much like the facility shown in Figure 11-1.

!Recent disasters have shown that citizens who have functional or medical deficits, are frail or elderly, reliant on medical devices, or socially or economically disadvantaged require a high degree of assistance and are more likely to require hospitalization during and following a disaster.

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D e l i v e r i n g A c u t e C a r e t o C h r o n i c a l l y I l l A d u l t s i n S h e l t e r s 11

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People with the following chronic diseases and related conditions arrived at emergency treatment facilities in New Orleans in the wake of Hurricane Katrina, September through October 2005:

Cardiovascular disease ■

Cerebrovascular disease ■

Diabetes ■

Renal failure ■

Chronic lower respiratory tract disease ■

Dental problems ■

Obstetric/gynecologic conditions ■

Chronic gastrointestinal conditions ■

Figure 11-1. Federal Medical Station Prepared for Patients With Complex Needs a

Federal medical station for patients with complex needs evacuated from the New Orleans area; set up before Hurricane Gustav on the campus of Louisiana State University, August 2008. a Photo courtesy of Robert Gougelet.


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Chronic pain ■

Hematologic/oncologic disease ■

Arthritis ■

The 2007 fires in Southern California and multiple international situations that resulted in the sudden displacement of people (3) have shown that the most strongly affected adults are likely to come from the following settings:

Skilled nursing facilities ■

Assisted living facilities ■

Board and care facilities ■

Homebound individuals who require durable medical equipment ■

Caring for these vulnerable people requires advance planning and coordination to ensure that the necessary medical equipment will be in place in order to meet the special needs of those with chronic or acute care medical needs if disaster strikes.

1. Respiratory Conditions

Displacement of the pulmonary patient during a disaster can result in sudden clinical deterioration if oxygen needs are not met. Oxygen suppliers have now built a robust mechanism for delivering oxygen to medical evacuation shelters; however, they are often delivered without necessary tubing or regulators, making the oxygen inaccessible to those in need (experience of author [AD] and personal communication with Hurricane Gustav medical volunteer). Additionally, patients who require over 3 L/min of oxygen consume resources more rapidly, thereby depleting the short supply. Access to shelters, communication, and power limit resupply by carriers; therefore, creative delivery options (including sharing and splitting oxygen) have been used in shelters.

Another consideration is that staff support to distribute and change tanks is not provided by oxygen companies. It is incumbent upon the frail patient, a family member, or a volunteer medical professional to change the tanks and ensure an adequate supply of oxygen. Respiratory therapists are traditionally not considered first-responder volunteers; however, those who have come to area shelters during a disaster find themselves to be the busiest workers (4). In care centers outside of medical facilities, where oxygen is not built into wall systems, creative connections of H-cylinders,

!Most affected adults are likely to come from the following settings:- Skilled nursing facilities - Assisted living facilities- Board and care facilities- �Homebound individuals who require

durable medical equipment- Hospice centers

!

!Oxygen suppliers have now built a robust mechanism for delivering oxygen to medical evacuation shelters; however, staff support to distribute and change tanks is not provided.

!


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proper use of regulators, and basic knowledge of changing tanks are required skills (5). Shelters need improved oxygen delivery systems, including oxygen-conserving or -generating equipment (compressors), to better care for patients with respiratory conditions.

Patients who are dependent upon ancillary equipment, such as home ventilators, bilevel positive airway pressure or continuous positive airway pressure ventilators, and nebulizers, are also affected by disaster/shelter situations. Workers with basic knowledge of setting up and troubleshooting these devices will be invaluable. All patients using durable medical equipment should have a disaster-contingency guide specific to their medical needs that includes plans for evacuation, necessary equipment/supplies, and social/family support.

2. Cardiac Conditions

The many chronic cardiac conditions pose challenging hurdles to those charged with emergency care in nontraditional settings. Many patients with chronic, severe cardiac conditions can be stabilized and managed at home using relatively high-tech devices and/or rigorous pharmacologic regimens. In a disaster, these same patients may present for care and shelter. Among them will be those with congestive heart failure (CHF); those with implanted devices such as left-ventricular assist devices (LVADs), pacemakers, and implantable cardioverter-defibrillators (ICDs); patients who require infusions of vasopressors and inotropic drugs; and those with hypertension (HTN). Many will also be oxygen-dependent. Because volunteer medical personnel may have minimal experience in caring for such patients, it is important to plan how the conditions will be managed.

a. Chronic Heart Failure

Patients with CHF are often managed (fairly intensively) as outpatients in specialty clinics and require close attention to weight gain and electrolyte management. Knowledge of these patients’ home drug regimens is important because unusually high doses of many drugs may be required. Given that patients with CHF often have physical limitations and may be unduly stressed by walking even short distances, availability of commodes and/or close proximity to toilets should be taken into account. Another consideration is sleeping accommodations because CHF patients are unlikely to tolerate lying flat on cots at night. Instead, it may be helpful to use alternative resting equipment such as reclining chairs or back elevation bolsters to ensure head elevation and prevent positional orthopnea.

b. Left-Ventricular Assist Devices and Other Implanted Medical Devices

An LVAD is currently used for 3 purposes: as a bridge to transplant, as a bridge to recovery, and, for patients who do not meet criteria for transplantation, as destination therapy (6). Because the power pack for the LVAD’s pump requires recharging at night, access to electrical power is necessary. (These patients typically carry a second power pack with them at all times.) Anticoagulation is also part of managing their maintenance. To ensure appropriate care of patients with CHF, disaster-preparedness plans should identify potential resources for consultation and management and/or criteria for transfer to a different level of care facility.


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Permanent pacemakers and ICDs are 2 other fairly common implanted medical devices. Patients with these devices are taught to carry their pacemaker implant cards with them, and that information should stay with them. Many patients with implanted devices routinely submit information about the function of the device to their provider (or device clinic) by a transtelephonic monitor, but it is possible that those providers will not be available during a disaster. Although most electronic equipment does not affect permanent pacemakers and ICDs, some may affect their function. Awareness of these is important to prevent unintended interference and malfunction. Devices such as ICDs generally function well, but shocks delivered by the device, especially if more frequent than expected, may signal something (eg, electrolyte abnormalities or dysrhythmias) that needs to be investigated and treated. Disaster-preparedness plans for management of these patients should identify available consultation resources, transfer criteria, and what to do with the devices in case of death (how to turn off the devices, etc).

c. Vasoactive Drug Infusions

Some hospitalized patients with very severe CHF and other cardiac conditions require continuous infusions of intravenous drugs to provide afterload and/or preload reduction, but they are stable and can be cared for at home or in extended care facilities. In a disaster, these patients may seek shelter in nontraditional healthcare centers. To accommodate them, experts who can provide consultative services (by phone or other means) should be identified in advance. Nurses and other personnel who know how to use the infusion devices are a must, as is access to user-guide information that will ensure appropriate troubleshooting of alarms. In addition, patients may need standby bags of their medication during their stay in the shelter. How to obtain the additional bags and how to place them in the infusion device will need to be determined. Infusion devices all have batteries, but because the battery life is limited to hours, a power source is needed for recharging.

d. Hypertension

In the United States, approximately 1 person in every 5 (18.38% of the population, or 50 million people) has hypertension, a condition that may be exacerbated by events that are stressful, such as disasters. In addition, patients may not have their medications with them and/or be unable to remember the medications they routinely take. Furthermore, the food available in shelters may be high in sodium, carbohydrates, or fat and therefore aggravate cardiac or other conditions. Treatment guidelines for both acute and chronic HTN should be available in every shelter.

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!

Disaster preparedness plans for management of patients with implanted cardiac devices should identify available consultation resources, transfer criteria, and how to handle the devices in case of death.


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3. Renal Conditions

One of the most vulnerable populations in a disaster is dialysis-dependent renal patients (7). The 2005 hurricane season exposed a need for formal coordination for this patient population and resulted in the formation of the Kidney Community Emergency Response Coalition (KCERC). The KCERC was formed by a number of government agencies and professional organizations to formally address the provision of dialysis to affected individuals during a disaster. The coalition recognizes that individual patients and volunteer providers will be at the forefront of disaster response and hope to supply expert guidance in the event that non-nephrology personnel are helping to care for dialysis-dependent renal patients outside of the usual settings, such as in a special needs shelter (8). Important concerns in mass-care or shelter facilities include providing a renal diet during or following a disaster, electrolyte monitoring, coordination of and transportation to and from dialysis, and care of infected shunt grafts. All of these become Herculean tasks when a disaster disrupts an entire region’s power, water, and the medical infrastructures.

4. Diabetes

Diabetes, which is becoming increasingly common, is typically managed with oral medication or insulin. Although glucose-monitoring devices are extremely common in hospitals and extended care facilities, they are not readily available in shelters. The devices may be relatively easy to obtain, but their acquisition in anticipation of need in a nontraditional setting requires planning. Because the food available in shelters is unlikely to meet the requirements of diabetic patients, the monitoring of glucose levels will be key to preventing complications. This is especially true for patients with diabetes who acquire an infection or have a wound or an injury.

5. Morbid Obesity

Shelters must be ready to accommodate the needs of morbidly obese individuals. Military cots are commonly used in shelters because they are small, light, and portable. However, they are designed for young, active-duty, healthy people and are inadequate for those who are frail, obese, elderly, or ill. Through personal experience in shelters with this population, one of the authors (AD) has noted that clearance of pulmonary secretions, respiratory difficulty (orthopnea), obstructive sleep apnea, and logistic considerations are significant issues. Often an obese patient will use 2 cots to sleep. However, when a fall occurs, significant manpower is needed to lift the patient back on to the cots. Using security, volunteers, and emergency medical services personnel to assist the healthcare worker minimizes injury to staff.

6. Cancer

Patients with hematologic/oncologic conditions may require laboratory monitoring and specific regimens to prevent infections and/or relapses. For example, neutropenic patients may need to be protected from exposure to infection and treated with antibiotics if necessary. Missed treatments may result in serious setbacks and increase a patient’s stress and concern. In some cases, therapy may be provided in the shelter setting, but guidelines are needed to determine the thresholds for such interventions. Cancer patients who are receiving brachytherapy may expose others to radiation, which generally must be avoided, especially for those most at risk, pregnant women and children. In such cases, physical distance between the patient and others (generally 6 feet or more) can be identified to prevent inadvertent exposures.


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7. Organ Transplants

Patients with organ transplants usually take immunosuppressant medications that require regular laboratory monitoring to ensure therapeutic levels. In addition, because their immune systems are suppressed, precautionary measures must be taken to protect them from infection. Grouping noninfected immunocompromised patients away from other shelter residents in areas where exposure to infection is less likely is important, albeit difficult in disaster conditions. Masks and other infection-control methods are essential to shield these patients from exposure to potentially lethal organisms.

8. Infectious Diseases

In a disaster, infections are quickly spread under even the most sanitary conditions. Infection-control practices should thus take into account opportunistic infections such as tuberculosis. Homeless persons are particularly at risk for opportunistic infections and may not be aware that they are sick. Although all recommendations for infection control may not be practical or possible in nontraditional care settings, personal protective equipment such as masks and gowns are essential to safeguard both caregivers and those for whom they care. Supplies such as liquid hand cleansers should be available, and families, patients, and staff should be educated through pamphlets, signs, and the like about the importance of sanitation and prevention. Basic topics should include how to keep the water supply clean, the need to ration water as required, toilet maintenance (number and locations), how to handle food preparation and distribution, cleaning of the shelter, and self-hygiene.

9. Psychiatric Conditions

Patients with a wide variety of psychological conditions may arrive at shelters, and some psychological conditions may be exacerbated by a disaster. Although people with some conditions, such as depression, may not pose any risk to others, people with other conditions, when placed under great stress, may manifest extreme agitation, aggression, or other potentially dangerous behaviors. Shelters will need specialists in psychology and mental health to determine how best to manage such patients. Much more commonly seen will be manifestations of anxiety, fear, grief, and depression associated with the disaster, separation from and/or loss of loved ones, and concern for the future.

10. Special Needs of Older People

Shelters must also be prepared to accommodate the evacuation of skilled nursing facilities or the arrival of a large number of displaced elderly patients. When elderly people are hospitalized or moved to a new location, even under routine circumstances, they may become significantly disoriented. This disorientation may be expressed as “sundowning.” People with this syndrome may have difficulty sleeping and may moan, scream, or have memory dysfunction during the

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Patients with transplantations are generally on immunosuppressant medications that require regular laboratory monitoring to ensure therapeutic levels.


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night. This not only is disruptive to others in the shelter but also stimulates a domino effect that results in fragile tempers the following morning. After a series of sleepless nights, psycho-social decompensation can occur in both staff and shelter residents. Anticipating such situations and preparing staff to manage and provide reassurance, often on a one-to-one basis, to affected residents is vital. It is important to ensure that staff has appropriate breaks and shifts in order to prevent fatigue. The use of social workers, psychiatric and mental health professionals, chaplains, and some lay individuals to help comfort and console patients and staff will be a useful intervention.

I I I . P l A n n I n g A h e A d f O r P A t I e n t S W I t h C O M P l e x n e e d S

Planning for disasters requires that community agencies prepare to meet the potential needs of a wide spectrum of vulnerable patients. An early step is to identify where such patients are located in the community. One source of this information is medical-supply vendors. Such knowledge may help communities project emergency power needs and contribute to the development of a decision-making schema for the care of vulnerable populations during a disaster. Essential elements include, for example, where to call for resources like electrical or battery power, when to transfer patients to a hospital or other shelter, who to call if equipment malfunctions, and where to get medications and supplies. Logistic matters to be addressed include arranging patient-care areas to maximize and/or share scarce resources, credentialing of providers, dealing with clinical deterioration of patients, and enabling family members to stay with patients with complex needs to assist them with activities of daily living.

Among the complications that may arise due to prolonged stays in shelters are decubitus ulcers, physical disabilities requiring physical therapy, and respiratory, cardiac, or metabolic decompensation. These can be prevented with support from physical therapists, nutritionists, and ancillary clinical providers. Social workers are a vital component of shelter operations because they assist with facilitating the patient’s return home.

Treatment guidelines are available for a wide variety of complex patient conditions, especially the relatively common ones, such as CHF, chronic obstructive pulmonary disease, diabetes, and hypertension (Table 11-1). Having hard copies of such guidelines available in shelters will ensure consistent care and help emergency workers cope with such disaster-related conditions as power failure. Finally, community planners should identify ways to support the home care of patients with complex needs and thus help them avoid the discomfort of being transferred to busy shelters. A recent report by the Agency for Healthcare Research and Quality suggests that telehealth and other technologies may be useful for managing and monitoring home-based patients (9).


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t a b l e 1 1 - 1 .A n t i c i p a t i n g t h e n e e d s o f S p e c i a l P o p u l a t i o n s : r e c o m m e n d a t i o n s a n d r e s o u r c e s

Recommendations Selected Resources a

General Disaster Web Sites

Cardiac Conditions

Respiratory Conditions

Centers for Disease Control and Prevention: Lists recommendations by specific disaster type (tornadoes, fires, hurricanes, chemical, bioterrorism, etc).

Society of Critical Care Medicine: Includes resources listed by specific disaster type as well as information related to the Fundamental Disaster Management course.

Congestive Heart Failure

1. Adhere to patient’s home pharmacologic regimen.

2. Use bolsters to elevate head at night. (Cots are often inadequate.)

3. Locate bed in close proximity to bathroom and/or commode.

Vasoactive Drugs

1. Keep user guide information for infusion devices with patient.

2. Identify resources for consultation and how to obtain additional bags of the infusion medications.

3. Ensure access to electrical outlet.

Hypertension

1. Be aware that disaster diets may be high in sodium and require some adaptation.

2. Adhere to patient’s home pharmacologic regimen if possible.

3. Keep hard copy of current management guidelines available for reference.

Implanted Medical Devices

1. Left ventricular assist devices: – Ensure available electrical outlet for recharging batteries.

2. Pacemakers and implanted cardioverter-defibrillators (ICD): – Pacemaker and ICD implant cards should accompany patients

and be kept with them.

3. Identify consultation resources.

4. Keep hard copy of current management guidelines available for reference and to determine need for anticoagulation.

5. Ascertain criteria for hospital admission.

6. Ascertain guidelines for what to do with implanted devices in case of death.

Necessary skills for providers include how to distribute and change oxygen tanks as well as how to troubleshoot home ventilators, BiPAP, CPAP, and nebulizers.

http://www.bt.cdc.gov/disasters/

http://www.sccm.org/Public_Health_and_Policy/Disaster_Resources/Pages/default.aspx

http://www.sccm.org/FCCS_and_Training_Courses/FDM/Pages/FDM_Resources.aspx

Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2001;38(7):2101-2113.

Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2001;38(7):2101-2113.

Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206-1252.

Goldstein DJ, Oz MC, Rose EA. Implantable left ventricular assist devices. N Engl J Med. 1998;339(21):1522-1533.

Gregoratos G, Abrams J, Epstein AE, et al. ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: summary article: a report by the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2002;106(16):2145-2161.

http://www.ahrq.gov/prep/projxtreme/

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t a b l e 1 1 - 1 .A n t i c i p a t i n g t h e n e e d s o f S p e c i a l P o p u l a t i o n s : r e c o m m e n d a t i o n s a n d r e s o u r c e s ( c o n t i n u e d )


Renal Conditions

Diabetes

Morbid Obesity

Cancer

Organ Transplants

1. Check availability of renal diet during and/or following a disaster.

2. Determine means of monitoring electrolytes.

3. Identify how patients will be transported to and from dialysis centers.

4. Identify how infected shunt grafts will be managed.

1. Adhere to patient’s home pharmacologic regimen if possible.

2. Obtain access to a bedside finger-stick glucose-monitoring device and supplies.

3. Keep hard copy of current management guidelines available for reference.

1. Identify means of providing larger accommodations (eg, 2 cots for sleeping, special chairs).

2. Bolsters for head elevation may be necessary to prevent orthopnea, etc.

3. Minimize injury to staff by asking security employees, volunteers, and emergency medical services personnel to assist healthcare workers with lifting obese patients and with other physical tasks.

1. Identify how essential laboratory monitoring will occur.

2. Determine need for grouping, social distancing, and use of masks and the like to prevent infection in immunosuppressed individuals.

3. Ensure that patients with brachytherapy avoid contact with other patients most at risk, pregnant women, and children. (May require distances of 6 feet or more.)

1. Identify how essential laboratory monitoring will occur for management of immunosuppressive medication.

2. Determine need for grouping, social distancing, and use of masks and the like to prevent infection in immunosuppressed individuals.

Kopp JB, Ball LK, Cohen A, et al. Kidney patient care in disasters: emergency planning for patients and dialysis facilities. Clin J Am Soc Nephrol. 2007;2(4):825-838.

AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus. Endocr Pract. 2007;13(Suppl 1):1-68.

Equipment for bariatric care may be bought or rented from a number of sources. Area suppliers of hospital equipment should be identified in advance.

www.bt.cdc.gov/disasters/disease/cancer.asp

www.cancer.gov/hurricanes

www.nih.gov/news/radio/sep2008/20080912NCIWalletCard.htm

Summary list of available guidelines: http://www.etco.org/transplantation_practice_guidelines.htm

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t a b l e 1 1 - 1 .A n t i c i p a t i n g t h e n e e d s o f S p e c i a l P o p u l a t i o n s : r e c o m m e n d a t i o n s a n d r e s o u r c e s ( c o n t i n u e d )


Infectious Diseases

Psychiatric Conditions

Prevent spread of infectious diseases by taking the following steps:

1. Ensure that personal protective equipment is readily available.

2. Supplies such as liquid hand cleansers should be available, and families, patients, and staff should be educated (through pamphlets, signs, etc) about the importance of sanitation and prevention.

3. Maintain a clean water supply, and ration water as required.

4. Determine how toilets will be maintained (number and locations).

5. Identify how to handle food preparation and distribution and cleaning of the shelter, and encourage self-hygiene.

1. Anticipate psychiatric issues and prepare staff to provide reassurance.

2. Prevent staff fatigue by scheduling appropriate breaks and shifts.

3. Call on social workers, psychiatric and mental health professionals, chaplains, and some lay individuals to help comfort and console patients and staff as needed.

http://www.bt.cdc.gov/

http://www.cdc.gov/ncidod/dhqp/a_z.html

www.apic.org/AM/Template.cfm

Managing psychiatric emergencies: http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijem/vol4n1/psycho.xml.

Ke

y

Po

in

ts

Abbreviations: BiPAP, bilevel positive airway pressure; CPAP, continuous positive airway pressure. a The listed Web sites are only a sample of available online resources. The reader is encouraged to access others.

d e l I v e r I n g A C u t e C A r e t O C h r O n I C A l l y I l l A d u l t S I n S h e l t e r S

Selected special populations of vulnerable patients may come to community shelters for ■

acute care needs during a disaster.

Unless communities consider the potential needs of the people who are affected by ■

disaster and prepare for them, many will come to the hospital for acute care needs, further straining available resources.

These fragile patients include those with complex disease conditions such as dialysis ■

dependent renal failure, chronic obstructive pulmonary disease, CHF, HTN, diabetes, obesity, and patients who are immunocompromised and at risk of exposure to potentially devastating infections.

Patients who are technology-dependent may include those with LVADs, pacemakers, ■

ICDs, and infusion devices for vasopressors and inotropic drugs.


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r e f e r e n c e s1. Sharma AJ, Weiss EC, Young SL, et al. Chronic disease and related conditions at

emergency treatment facilities in the New Orleans area after Hurricane Katrina. Disaster Med Public Health Prep. 2008;2(1):27-32.

2. Washington Post/Kaiser Family Foundation/Harvard University Survey Project. Survey of Hurricane Katrina evacuees. Henry J Kaiser Family Foundation Web site. http://www.kff.org/newsmedia/upload/7401.pdf.

3. Nieburg P, Waldman RJ, Krumm DM. Hurricane Katrina. Evacuated populations: lessons from foreign refugee crises. N Engl J Med. 2005;353(15):1547-1549.

4. Devereaux A. Shelter medicine: beyond the first and second response. Chest Physician. February 2006;1(2):13.

5. Walsh TJ, Orsega S. Lessons from Hurricane Rita: organizing to provide medical care during a natural disaster. Ann Int Med. 2006;145(6):468-469.

6. DeRose JJ Jr, Umana JP, Argenziano M, et al. Implantable left ventricular assist devices provide an excellent outpatient bridge to transplantation and recovery. J Amer Coll Cardiol. 1997;30(7):1773-1777.

7. Kopp JB, Ball LK, Cohen A, et al. Kidney patient care in disasters: lessons from hurricanes and earthquake of 2005. Clin J Am Soc Nephrol. 2007;2(4):814-824.

8. Kopp JB, Ball LK, Cohen A, et al. Kidney patient care in disasters: emergency planning for patients and dialysis facilities. Clin J Am Soc Nephrol. 2007;2(4):825-838.

9. Knebel A, Phillips SJ, eds; Agency for Healthcare Research and Quality. Home Health Care During an Influenza Pandemic: Issues and Resources. AHRQ Publication No. 08-0018. Rockville, MD: Agency for Healthcare Research and Quality; July 2008. http://www.pandemicflu.gov/plan/healthcare/homehealth.html.

W e b S i t e sSpecial Needs Shelter Program. Florida Department of Health. http://www.doh.state.fl.us/PHNursing/SpNS/SpecialNeedsShelter.html.

Statistics About Hypertension. Wrong Diagnosis. http://www.wrongdiagnosis.com/h/hypertension/stats.htm.


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objectives - society of critical care medicine | sccm

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