Translating Practice into Policy: Disaster Nursing and Research in the American Red Cross

 Background

Multiple disaster events since 2005 have highlighted gaps and inconsistencies in collection and use of data on behalf of disaster shelter populations in the entire disaster cycle of prepare, respond and recover.  There is a paucity of evidence-based research in publication that describe systems for identifying needs of those at-risk within the population-based, non-medical setting of a disaster shelter.  Morbidity surveillance in congregate living shelters has not been well understood or incorporated into nursing policy and practice. There is a need for qualitative data surrounding disaster related fatalities to inform preparedness messaging.  The multiple people, organizations, policies, and community expectations involved in planning for and responding to a disaster reflects the complexities described as a wicked problem. That is, it requires non-linear thinking and multiple stakeholders’ contributions to solve for the best strategy.  American Red Cross disaster health services leadership have engaged multiple partners to assist with design, collection and analysis of critical data available during the response to a disaster to inform training, response, and messaging to support prevention of morbidity and mortality in disaster impacted communities.  

Methodologies

American Red Cross nursing disaster responders use quantitative and qualitative strategies to gather data. Data from the 2011 massive tornados in Alabama, a smaller tornado in North Carolina and Hurricanes Irene, Isaac and Sandy contributed to these studies.  In each of these disaster operations’ instruments and processes were trialed, interviews were conducted, and new ideas were tested. 

Field-based pilot studies were done to identify needs of actual or potential at-risk clients in shelters through a mixed-method approach.  Populations in four congregate care shelters from two different disasters of 2011 were included. Clients were interviewed using screening instruments in an attempt to determine the “best” questions; nurses were interviewed to determine gaps between intake questions/answers, and clients’ support needs identified later; and themes between disasters were identified to inform design of the intake, health and mental health needs screening system.

Daily (24-hour) tally of shelter population health categories were instituted.  Categories include Injury, Illness, Symptoms, Exacerbation of Chronic illness, Health care maintenance,  Behavioral and Mental Health, and Functional needs support services. As health staff in the shelter identifies a client with a need, that contact is counted, and each contact is collected on a worksheet.  At the end of the 24-hour period, this aggregate morbidity is then faxed, e-mailed, or sent by courier to nursing leadership at the local disaster operations headquarters. From there, acute illness concerns are reported to local public health, patterns of illness or injury are considered, and all reports are forwarded to leadership at National Headquarters of the American Red Cross and the epidemiology section of the Centers for Disease Control. 

Nurses collect fatality data from medical examiners and coroners to verify number and identity of individuals suffering a disaster-related death. Once the identity of a victim of the disaster is verified, the integrated care team, led by nursing, reaches out to the family of the victim to conduct an interview and to offer support.  Once the interviews are completed, they are de-identified and sent to CDC for a comprehensive analysis of the deaths pertaining to that specific disaster.

Results

The intent of intake screening was to identify activity of daily living (ADL) support needs, health and mental health needs. The studies found that screening as people arrived at the shelter was insufficient to understand the scope of clients’ needs.  Shelter residents were newly displaced, unfamiliar with what sheltering might mean, preoccupied with concerns related to the disaster such as losing their home, family members, and their future.  The setting of intake at the shelter registration desk provided little or no privacy.  Registration workers were reluctant to ask questions that might either feel too intimate, or have an answer that the registration clerk could not address. Interviews of clients done on the 3^rd shelter day showed that many needs were identified that had not been noticed prior to that day.  Nurse interviews showed that by the 3^rdday clients were more comfortable with the setting, less anxious about the evacuation, more familiar with and trusting of the shelter staff, and thus more able to share their health, mental health and ADL support needs. In three of four shelters, the population with functional, health and mental health support needs was double what predictions using county census data were.

Content and process training for daily surveillance improved nursing awareness of the value of this daily review.  The system is designed to observe for acute illness and injury as well as create a platform for longer-term analysis of patterns for predictive illness and injury of populations in disaster.  Development of a more robust and comprehensive process for morbidity surveillance demonstrated in 2013 that chronic disease management, minor acute illness and behavioral health issues were the most common concerns seen in disaster shelters. 

Qualitative data, which surround the circumstances of fatalities, are not captured in coroner, medical examiner reports or electronic death records.  In the massive tornados in Alabama in 2011, 21.9% of deaths were directly or indirectly related to head trauma.  In Hurricane Sandy, 34.2% of the deaths were related to drowning. The 2013 study of mortality data from Hurricane Sandy showed significant improvements in accuracy of matching Red Cross identified families to local coroner/jurisdiction knowledge and demonstrated that the Red Cross data is comprehensive and includes details not typically available to a medical examiner.  This information contributes to better knowledge of precipitating/contributing factors to disaster related deaths.

Application

The Red Cross shelter registration intake screening process has been altered to offer multiple opportunities for clients’ needs to be identified and addressed. An initial intake at the registration desk makes two observations and asks two questions of new shelter residents to help them immediately if needed, and create an awareness that help is available.  The intake is supplemented by a Cot-to-Cot methodology of disaster health services nurses making at least daily rounds of the shelter to interview individuals and families, and assess the community for ADL support, health and/or mental health needs.

Daily aggregate morbidity surveillance was strengthened during Hurricane Sandy when the CDC Epi-Aid program was triggered to assist the Red Cross gather and analyze shelter morbidity data in New Jersey. Previous education for Red Cross health Services leadership on the process and importance of aggregate morbidity reporting increased the diligence of collection and transport of data to CDC and Red Cross headquarters.

The American Red Cross Preparedness unit and federal response partners are utilizing data collected by family interview with Red Cross disaster nursing surrounding disaster deaths to develop future content of preparedness messaging.

Due to the nature of voluntary deployment, Just-in-Time training modules for Registration and Cot-to-Cot, Managing Aggregate Morbidity and Mortality and the Integrated Care Team process have been created. One of these modules uses Voicethread technology for audio and visual training; two of the modules are PowerPoint presentations.  Two of them use algorithms to help with decision-making, and all are 30 minutes or less and can be done as part of orientation at the Disaster Operations site. Intake screening, Cot-to-Cot, and Surveillance content have been added to a national program to train student nurses in sheltering.

CDC and Red Cross have produced and presented national trainings based on the data from these collaborations to educate others in disaster planning and response.  The authors have done multiple trainings to the volunteer workforce, to disaster response partners, to the disability advocacy community and others. 

Limitations

There are several chronic limitations to doing research in time of disaster.  Disasters are quite fluid in the response phase with populations often moving from address to address. Disasters are capricious in their destruction, creating geographic barriers to recovery and demographic disparities in impact.Entire communities are often dependent on donations for response and recovery support, often limiting available resources. For the Red Cross the entire disaster-nursing workforce is voluntary.  Maintaining a workforce that has training in the latest procedures, such as Cot-to-Cot, or surveillance tools is very difficult. There is a very tiny cadre of volunteers that come to “most” disasters, leaving a significant part of the workforce as essentially ‘new’ each time.

Future

Additional tools are being added to the Cot-to-Cot process model to better assure success in identifying ADL support, health and mental health needs.  A new job aid called CMIST, was pilot-tested in Hurricane Sandy and has been added to the Cot-to-Cot assessment process.  CMIST organizes assessment of client needs into functional categories of Communication, Maintaining Health, Independence, Services/Support/Self-determination, and Transportation.

Recommendations from these research projects inform policy content for federal response partners in the United States. They have been shared with the Canadian Red Cross.  The process model of Cot-to-Cot, the CMIST strategy for identifying at-risk individual and population needs and use of the surveillance instrument are being taught to local public health departments, student nurses, and new volunteers planning to deploy.  The future promises strengthened messaging in preparedness, and improved support during response and recovery for at-risk populations and communities impacted by disaster.