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Monday, December 18, 2017

Natural Disaster Planning for At-Risk Hospice Patients

by Shayna Rich

This year, our hospice went through Hurricane Irma, and although its destruction was limited in Florida, our preparation was based on predictions for major damage. In northern Florida, that means substantial flooding and wind damage destroying the electrical grid. Other parts of the country have different safety concerns (fires, tornados, snowstorms) but the solution may be the same—moving patients from out of their homes and into facilities. This article is the first in a series about our hospice’s response to the storm emergency.

We triaged patients to maintain their safety, based on their risk of flooding at home and the risk of electricity loss (especially for patients who relied on high oxygen flows). We moved high risk patients to care centers with low flood risks and back-up electrical generators. This included moving at-risk patients out of hospice care centers, assisted living, nursing homes, or their homes.

At my care center, we took 16 single-occupancy rooms, and set it up for 30 patients and their families (double-occupancy for all but 2 rooms). Space was cramped, limiting privacy and comfort. Rooms were set up with portable hospital beds and sheet curtains as dividers. To maximize safety and comfort, we organized patients based on the criteria below.

General Criteria for Rooming (Determined most room assignments)

Gender: The initial criterion was the most straightforward. We assumed that rooms should be single-gender for patient comfort. This assumption was the strongest limit to our ability to accept patients, as we ended up with a (predictable) predominance of women. This necessitated rearranging rooms on an ongoing basis, to maximize occupancy.

Oxygen needs: Most respite patients came to the care center for concerns of oxygen availability (high-flow oxygen needs and high risk of power loss), so this was a critical consideration. Our rooms were designed as single occupancy, and each had a single oxygen outlet. We obtained a few oxygen concentrators, but they required available hardened electrical outlets to continue to work after power loss. We spread our oxygen-dependent patients across rooms to limit the need for concentrators.

Acuity: Single rooms were reserved for patients who were admitted for General Inpatient Care (GIC) level of care, especially those with agitation, delirium, or other difficult-to-manage symptoms. Patients with high acuity and those with fall risk were roomed closer to the nursing station, for more frequent monitoring and easier access to medications. This was particularly critical given the high total workload for nurses and CNAs.

Prognosis: We roomed patients with similar prognosis and activity level together. In most cases, this meant rooming patients who were actively dying together or keeping them in single occupancy rooms. This also ensured that patients who were alert and liked to interact and talk to their roommate had someone available who could respond. They could also watch TV or talk without worrying about overstimulating a dying patient. Importantly, we attempted to avoid patients having to watch a roommate die a few feet away.

Any attempt to predict prognosis is imperfect, especially in the setting of increased stress levels due to evacuation and concern for family safety. It was inevitable that a few patients declined and died faster than expected. The body was removed from the room as quickly as possible.

Established patients: We avoided moving patients who were already settled in a room, and tried to allow these patients to remain single-occupancy. This consideration often overlapped with acuity and prognosis, as existing patients had been admitted for management of symptoms or terminal care. Expectations had been set at the time of admission, and it was easier to avoid the inconvenience and extra logistics of moving patients and beds when possible.

Additional Criteria to Consider (Affect 1-2 patients each)

Infection risk: As with most hospice care centers, we have a small number of infection control rooms. These rooms are much smaller than our other rooms due to the attached alcove for gowning, so they were only practical as single-occupancy rooms. These were reserved for patients at high risk of infection (e.g., patients with cystic fibrosis or those with tracheostomy). We did not have any patients with active infection during the storm, but they would also have been appropriate for quarantine in these rooms.

Temperature and air flow: One reason to room oxygen-dependent patients together was temperature and air control—COPD patients usually prefer a cool room with high air flow. Throughout the building, we turned down the thermostats to cool the building in anticipation of loss of power and air conditioning (which is not on generator backup), but it is best to match environmental preferences. For one patient, this was untenable, as he preferred a temperature in the 80s Fahrenheit. Unfortunately, we initially roomed him with a patient who preferred a temperature in the 60s. We separated them the following day, but it made for a highly disturbed night.

Other electrical needs: Although most hardened electrical outlets were used for oxygen concentrators, it was important to consider whether patients need electrical appliances to manage their symptoms. This came into play with need to power beds (especially low air loss mattresses, which may flatten and become hard if they lose power) and fans.

Family: We opened our care center as a shelter for family to ride out the storm with their loved one. Of course, the number of pull-out chairs and cots in the building were limited. We brought in extra cots, but most were outside of patient rooms. Some families were so large and boisterous that they strained our rooms even as single-occupancy. We considered both the number of family members and their boisterous or argumentative nature when determining who should be roomed together or given a single-occupancy room.

Psychological concerns and stress: A few of our patients had active psychological diagnoses and most of them had a high stress level, even before the storm. For example, one of our respite patients had severe OCD and did not want to leave home, so he found it hard to have a roommate. Some of our other patients had a much harder time with storm-related anxiety and uncertainty about their family and homes. Rooming as double-occupancy was stressful to all, and psychological concerns could not trump safety-based concerns. But where possible, it was helpful to consider personality match and stress levels, splitting up anxious patients.

This list of criteria is not comprehensive and flexibility is the best guide for managing patients in an emergency. We had several patients evacuated from a nursing home in the middle of the storm unexpectedly, and deaths or changes in acuity necessitated moving patients. As described above, sometimes patients had to be moved to accommodate symptom management or patient preferences, but these criteria provide some basic ideas for arranging this complicated puzzle.

Shayna Rich, MD, PhD, is an associate medical director for Haven Hospice in Lake City, Florida. She is glad to help others think through emergency planning, and she is glad that this year’s hurricane season is over.

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