The array of challenges posed by medical special needs (MSN) populations is among the many lessons highlighted during the 2005 response to Hurricane Katrina. However, even defining the demographics of MSN populations can be a difficult task, partly because and MSN population is only one component of the more broadly defined “vulnerable populations” – a term that includes those with socio-economic, language, and/or cultural barriers that hamper their ability to react in accordance with the instructions provided to the general population.
MSN populations include those with physical disabilities, other debilitating health conditions, and mental health issues. They require special attention in order to ensure safety and sustainment of their care throughout each phase of an emergency. However, because the range of functions within these populations is so diverse, specifically defining an MSN population and determining its unique needs can be an extremely difficult if not impossible task, making MSN planning and response among the most challenging issues facing medical responders both before and during public health emergencies.
Although many members of the MSN populations may not require hospitalization, they often are suffering from conditions that exceed the capabilities of the general population shelters managed by the American Red Cross. The ambiguous nature of an MSN population definition is further complicated by the growing number of Americans with varying degrees of disabilities, including those with multiple disabilities.
Some Plans Already in Place – But Additional Work Needed
Advance planning at the local level is the key to the successful management of MSN populations during a crisis. Although some at-risk hospitals already have comprehensive evacuation plans supposedly in place, many – probably most – of those plans still need additional work. The Joint Commission has continued to increase emergency preparedness requirements for health care facilities – to prepare workable evacuation plans, for example. However, many of those facilities apparently are still counting on a “sheltering in place” strategy, regardless of circumstances.
Long-term care facilities – e.g., nursing homes – also have developed evacuation plans, but many of these plans do not go beyond the confines of the facility’s own parking lot. Measures to facilitate evacuation outside of the immediate area are often lacking because many plans are limited to a facility’s fire-evacuation procedures.
The National Disaster Medical System (NDMS) possesses some resources that can be used in the evacuation of special needs populations; however, the NDMS option should be used only as a last resort – for two reasons: (a) The use of NDMS assets requires a presidential disaster declaration; and (b) The military aircraft used for NDMS air evacuations can prove to be a harsh environment for MSN evacuees. It is therefore very important that local responders and planners understand NDMS’s roles and limitations.
The NDMS Disaster Medical Assistance Teams (DMATs) at air hubs have limited patient care capacity. DMAT Strike Teams may be deployed, though, with a mission to provide workforce protection for only the staff assigned to the air hub itself, and therefore would have no patient care mission. Given the overall environment of care available at air hubs, the NDMS evacuation of MSN populations should focus specifically on low-acuity MSN evacuees. Higher-acuity patients should be evacuated, therefore, either by ground transportation or, in some rare occasions, by smaller fixed-wing aircraft – not only to provide a more stable transport environment but also to reduce the resource burden imposed on the NDMS system by high-acuity patients.
The Three Groups Most Seriously Endangered
In addition to the patients already in health care facilities, there are three primary MSN groups that require special consideration during a disaster – those who are: (a) medically fragile; and/or (b) technologically dependent; and/or (c) members of high-risk groups. The medically fragile population includes patients living outside health care institutions who require some level of care from a provider such as a home health nurse. Some patients in this category, of course, may be suffering from one or more chronic conditions, and/or require regular monitoring, or both – but others may simply need assistance with the usual activities of daily living.
Those who are technologically dependent include patients who depend on power for mechanical devices, or oxygen to sustain life and/or enable regular activities of daily living – e.g., those on ventilators, dialysis machines, or other devices used to sustain their normal everyday health. During large-scale disasters, the provision of oxygen is a particularly difficult challenge – which is complicated, moreover, by the requirement of oxygen vendors to refill only their own tanks and not those of other vendors. (Unfortunately, this restriction may preclude planning for a blanket contract with a vendor to provide oxygen over a wide area.)
High-risk populations include those who are typically able to “thrive and survive” in normal circumstances, but during a major disaster may require additional support. This includes individuals recently released from a hospital setting – e.g., post-surgical patients, people requiring life-sustaining medications and/or home IV therapy, and pregnant women as well as newborns.
Probably the best way for emergency planners to identify the individual members of MSN groups is by contacting local disability organizations, which can provide details on where various groups of high-risk or disabled individuals may work or live. An MSN registry may also be a valuable preparedness tool in pre-identifying the medically fragile, technologically dependent, or high-risk groups.
Gradual & Continuing Improvement; Again, Additional Work Needed
Fortunately, MSN shelters have evolved, and improved, significantly since the 2005 response to Hurricane Katrina. Lessons learned in recent years have shaped the role and function of MSN shelters. The planning and responsibility often falls on local and state public health agencies, many of which have risen to the challenge. For example, Florida, Texas, and many other states have developed detailed plans and guidelines for MSN shelter operations.
It is important that MSN shelter facilities be identified in advance because the MSN populations usually require more space per person than is available in a general population shelter. The latter are typically based on 40 square feet per bed/cot, but MSN shelters usually require twice as much space – i.e., 80 square feet per bed/cot. The additional space is needed for medical stations, medical administrative areas, and patient isolation areas.
As previously mentioned, there is a broad spectrum of MSN populations, so it is important to establish sheltering categories. “Cohorting” those who simply need evacuation assistance with those who require intensive 24-hour medical support is a mistake. A clear delineation must be made, therefore, between those in need of medical care and those who can be supported in a shelter environment designed for the general population.
Staffing levels for each MSN shelter are, or should be, established on a case-by-case basis depending on the size and medical needs of the population being sheltered. It is therefore important to maintain situational awareness when a community receives evacuees for sheltering. This is usually, and most easily, accomplished by establishing reception locations for all evacuees. As the individual evacuees register, referrals/assignments can be made to the appropriate shelter location – and the equipment and supplies needed to support them also can be assured.
The Most Difficult Challenges: Communications, and Dialysis Needs
During a major public health emergency, communications is almost invariably the key to success, and communications with the MSN audience must be given special consideration in developing a general communications strategy. However, according to a 2005 National Organization on Disability Harris Poll Survey, only 16 percent of emergency preparedness awareness campaigns directed at people with disabilities are in accessible formats. In addition to mass media outreach, the Emergency Alert System, reverse 911, and registration of MSN cell phones may prove to be effective solutions – at least in part. Nonetheless, the MSN demographics within each community and a planning framework that will facilitate the communications needed must be defined much more precisely.
Another difficult MSN challenge involves the need for effective and continuing pharmacy support. Evacuees should of course be encouraged to bring their pill bottles with them; by the same token, though, commercial pharmacy vendors should be invited, during the planning process, to help establish the approaches needed for refilling critical prescriptions in the event that members of the various MSN populations are displaced.
There also must be a plan that takes the special needs of dialysis patients into account, particularly the availability of dialysis services within close proximity. There have been incidents in recent disasters in which dialysis services were “offered” to the patient but, because of the travel distance required, had to be refused. Ensuring the availability of dialysis services will continue to be a challenge during and after major evacuations. If a dialysis center has been “hardened” to withstand a certain amount of damage, its continued availability may discourage some patients from following an evacuation order. On the other hand, if dialysis centers are closed throughout a relatively large geographic area, the only option left may be transporting MSN patients considerable distances to meet their special needs.
For both the pharmaceutical and dialysis issues, the private sector providers are the greatest allies of preparedness and response. They simply need to be engaged more closely in the preparedness process by local and state officials as well as their own stakeholders.
Bruce Clements is the Public Health Preparedness Director for the Texas Department of State Health Services in Austin, Texas, and in that post is responsible for health and medical preparedness and response programs ranging from pandemic influenza to the health impact of hurricanes. A well-known speaker and writer, he also serves as adjunct faculty at the Saint Louis University Institute for BioSecurity. His most recent book, Disasters and Public Health: Planning and Response, was released in 2009.