Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
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3. Focus Group Results
The results of the six focus groups are organized into topic areas:
- Disaster preparedness and planning activities (3.1).
- Special needs identified by nursing home staff (3.2).
- Potential roles facilities could play during a disaster or other public
health emergency (3.3).
- The influence of State regulations of preparedness and planning (3.4).
In addition, there is a section that explores additional topic areas
brought up by focus group participants that were not specifically included
in the protocol.
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3.1. Disaster Preparedness and Planning
Nursing homes have plans in place for some public health emergencies but
have not done planning specific to bioterrorism.
For the most part, participants reported their facilities had done planning
for disasters or emergencies such as fires, major snow storms, earthquakes
and hurricanes. However, only a couple participants reported planning
activities specific to bioterrorism. Many participants acknowledged
the importance of planning for bioterrorism or infectious disease outbreaks
such as flu (and tended to categorize these two events together), but most
admitted that it was "not on the radar screen," far down on the "list
of priorities" or had "fallen off the table" in the years
following 9/11. Several facilities reported developing new policies
and procedures specific to anthrax.
For the most part, participants noted that their State regulatory and licensing
agencies require they train staff for fires and other "disasters," but
bioterrorism planning has never been required:
The State requires that we have disaster training and fire drills. We
do drills for earthquake or power disruption... But terrorism, disasters,
things like that have not been part of the required drills... have
not been part of my planning.
We are required to have 2 disaster drills a year. We do take into
account fires, power outages, earthquakes, tornadoes... We've
not really done much with bioterrorism.
We don't really have anything set up that's formal for
bioterrorism. We do have disaster preparedness but not specifically
targeted to bioterrorism... fire, weather related, if we get to the
point where we need to move residents out.
One participant noted that a comprehensive disaster plan, including bioterrorism
preparedness, is "required as part of Joint Commission (JCAHO) accreditation."
For the few facilities that reported some level of bioterrorism or infectious
disease planning, the level of planning varied greatly. One facility
reported developing a plan in the immediate wake of 9/11 but the participant
noted "I can't tell you a single thing that's in it or where
it's located." Another participant reported using in-service
trainings to review "signs and symptoms or what to be aware of" as
well as what measures to take to protect residents, staff, and the facility
if an infectious agent is identified. These trainings tended to be short
(5 to 10 minutes in duration) and focused on flu, norovirus, and other common
illnesses. Another participant who had been affiliated with the military
before taking her position with the nursing home reported:
We've looked at our infection control and how we would handle
a biological agent, how we would detect that. We have periodic
training with the staff and try to go through each of the different areas. We
have a rather... thick disaster manual. So at staff meetings
we try to go through each of the sections and keep it in the forefront
of their minds.
This was undoubtedly the most developed bioterrorism response among all
nursing homes with which we spoke. Another facility had recently been
involved in a HAZMAT scare when a contaminated patient was admitted to the
attached hospital. This participant also reported a higher level of
We have been involved with the bioterrorism process on the hospital
side with the grant writing in terms of getting decontamination showers
and some of the equipment... We recently spent time brushing up on bioterrorism
and chemical effects.
All nursing homes conduct drills and staff trainings, but topics
addressed in training are highly dependent on facility location.
All focus group participants reported conducting fire and disaster drills,
as required by State licensing and regulatory agencies. Quarterly fire
drills and semi-annual disaster drills appeared to be the norm among most
facilities, although some facilities held more frequent disaster drills:
We do 12 hour shifts so we have 2 shifts; both do quarterly fire drills
and semi-annual disaster drills... In addition, we do an in-service,
once a year. We have a big fire and disaster in-service for all staff.
Because when you look at just doing drills four times a year and disasters
twice a year to two shifts, we may miss some of our employees.
[We] do fire drills, and once a quarter we have a disaster drill... whether
it's an external disaster where we're taking in patients or
an internal disaster where we have to ship patients out... it's
done on all three shifts each quarter. It's a State requirement.
The types of disaster events that facilities focused on depended on the
types of natural disasters prevalent in their location. Facilities
in Southern California, Oregon, and Washington tended to focus on earthquake
preparedness: "At least once a year we do a disaster drill... that
is all internally focused. Usually we pretend it's something
like an earthquake." One facility described an elaborate drill
involving volunteers that act like patients and wear make up and tags that
describe their medical condition:
At least once a year... we have the facility suffer an earthquake. We
scatter people around with various identification items on them, and we
have a command center that we've established though this training
process... staff have to find people, triage them. We have a
disaster at such time of the day that the shift changes.
Facilities in Southern California also reported preparing for wild fires
while facilities in Washington and Oregon were more concerned with major snow
storms and flooding. Participants in North Carolina were concerned with hurricanes
and flooding while participants in Utah mentioned tornadoes and power outages. All
facilities reported tailoring their disaster plans to these events.
Nearly all participants agreed that high staff turnover rates were a significant
barrier to ensuring that staff are adequately trained for a disaster. In
general, participants stressed that they go over disaster activities during
orientation but expressed concern about whether this level of training is
adequate. According to one participant, "we try to emphasize
where to find information on what to do rather than what they should do". Other
participants reported spending a significant amount of time addressing the
details of the disaster plan with new staff:
I do an orientation myself with all the new employees that specifically
deals with disaster and fire drill rules. We go over where the electrical
shop is and if it's an earthquake we go over where the main gas line
turn-off is (in case there's a rupture in the line) and the main
line water cut-off. I cover that specifically with each new employee.
I think you just have to ensure that in your general orientation there
is a safety portion and that people go and see where the gas the water
and electricity shut-off areas are so they get the basics... You have
to make sure that people know what to do.
Differing levels of local coordination around disaster planning
are evident in different States.
A consistent theme across focus groups was the lack of involvement in local
or State emergency planning activities by nursing home facilities. While
several participants reported being involved in emergency or disaster planning
meetings that took place immediately after 9/11, these meetings ended up
being more information for nursing home administrators. According to
After 9/11... [our county] had a focus group looking at
these issues... they were very focused on trying to organize within the
county and included LTC in the focus but... you feel like you're a fly
on the wall... there are hundreds of people there from major agencies, fire
and police... I went to a couple meetings but it was more informational for
me than giving input or trying to say 'we offer these services.'
One State had recently organized an emergency and disaster planning forum
specifically for long-term care facilities that included a "task force
of nursing homes." Focus group participants reported that representatives
from that State asked for input on changes to rules and regulations that
might be necessary in the event of an emergency. Participants in other
States reported trying to coordinate with local or State emergency planning
agencies with little success. One participant noted that she "attempted
to get our county disaster preparedness representative involved with our
facility" but was never able to. Another participant reported, "We
haven't had much support from our local government. When you
try to contact them to get somebody out to come to the building to help,
there's really nothing or nobody available." Other focus
group participants reported speaking with city or local community emergency
planning agencies but did not find the interactions helpful:
We've been working with the city, local community services, and
talked with them. They had some suggestions... we talked abut [our
disaster plan] and reviewed it. They really wanted to focus on the
fact that for the first 72 hours we're on our own. But we
want to think longer term than that.
One participant pointed out that the local health departments in more rural
areas of the State are "less effective" than those located in
urban areas, making coordination even more difficult in these areas. Several
participants suggested that this lack of coordination at the local level
jeopardizes the utility of the disaster plans that nursing homes have put
in place because they will unknowingly be relying on the same resources as
other organizations in their communities. According to one participant, "I
bet our disaster plan and the one of the organization next door are both
relying on the same five ambulances."
Participants in one State were particularly adamant that nursing homes should
not be included as a resource in local or regional disaster plans. According
to one participant, "a nursing home historically is not part of any
disaster plan... when you think of a disaster plan, the community number
one resource: hospital. Nursing home is really not part of that
equation." Facilities expressed a number of reasons why nursing
homes are not suited to be a good resource. One participant pointed
out that only nurses are available for patient care because "the doctor
doesn't stay on site at the nursing home." Another participant
stated that while nursing homes often have the largest facility in many
nursing homes would not have that space available" because they are "not
designed to accept additional patients." Other facilities, such
as schools, have large auditoriums and lunch rooms that could be used to
help community members. Two participants started negotiations with
local community services but eventually backed out because "the administrative
decision of the facility was that we have other things on the fire that are
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3.2. Special Needs of Nursing Homes
Nursing homes have concerns about caring for special patient populations
during an emergency.
Most focus group participants reported that one of their principal concerns
in a disaster situation would be caring for the special populations in their
facility with limited cognitive and/or physical abilities. Caring for residents
with Alzheimer's disease or dementia during an emergency situation was of particular
concern for many facilities. Participants stressed the importance of maintaining a
calm, routine-based environment to avoid "losing this group to bad
behaviors." One participant explained that these patients are especially
vulnerable to the stress of a disaster. If pharmaceutical supplies ran out or were
destroyed and these patients were without their medications, "it could be a
very dangerous situation" because "without their meds [these patients]
are extremely dangerous to themselves and others."
Residents with Alzheimer's and dementia are typically located in locked
units where staff can monitor them very closely. Some facilities indicated
that they have monitoring systems (e.g., WanderGuard®) in place to prevent
residents with these conditions from wandering beyond supervised areas. In
the case of a power outage, these systems would cease to function (as they
require electricity), resulting in the need for additional staff to supervise
and redirect these residents to keep them safe. Two participants remarked
on redirection of wanderers:
[Our last stage Alzheimer's folks] would absolutely not know which
way to go. You would have to have staff down there doing constant redirection... You
would need to have concentrated staff down there.
We would try to assign somebody to stay by the main entrance door. So,
if they did make their way down the elevator if it's working... Of
course, in a power outage, it wouldn't be... But, if they did
manage to go down the stairs, there would be somebody there stationed.
That is the primary space that they would be able to get out. Even if the
system went down, they would be caught.
When asked, not all of the facilities with these monitoring systems knew
if their systems were hooked up to the generator. Even in cases where
these systems are hooked up to the generator, concerns about the longevity
of fuel supplies would be salient.
Focus group participants also addressed the increased time and attention
that would need to be devoted to patients lacking the cognitive skills to
understand and/or communicate about an emergency situation. Some facilities
reported having formal procedures in place for handling such patients in
an emergency. One participant explained that "just going around
and letting them see you and touching them and saying 'It's okay,
we've got it under control' is a very positive thing." However,
this would require additional staff that may or may not be available.
While a few focus group participants briefly touched on the special needs
of high-fall patients, concerns about caring for patients with limited physical
abilities typically arose in the context of logistical difficulties involved
in evacuating them. One participant shared her fear that the equipment
(e.g., wheelchairs) needed to transport bed-bound and vegetative patients
would be destroyed in the disaster. Another participant explained that his
staff has been trained in performing "blanket and emergency carries" to
handle circumstances such as these.
Concerns about staffing in an emergency were universal.
Adequacy of staffing impacts the ability of nursing homes both to successfully
maintain normal operations for their current residents and to take on additional
roles during an emergency. A number of focus group participants emphasized
the importance of maintaining normal operations and standards of care to
the best of their ability in an emergency. They acknowledged that
this would be extremely difficult to achieve without additional assistance,
much less with the reduced staff that they would likely have given the
Our facility would be in dire need of assistance if not
enough staff came in. In the event of a crisis, we would need more staff
Many facilities had clearly given substantial thought to how they would
induce the staff needed to maintain normal operations to stay at or come
to work. A few nursing homes said they had facilities available
to care for staff member's families and children and would encourage
staff to bring their families. Other facilities were prepared to provide
nursing staff with rooms and food. One participants remarked "... if
[staff] are unable to get home or there is a possibility that they won't
be able to get back we do have them stay in the facility, give them a bed,
they can stay right there." Some nursing homes mentioned having
the capacity to care for children of staff that report to work. According
to one participant:
One of the things I tell staff is, 'In the absence of communication,
come on in. Bring your families... we will provide.'... Their
homes may be destroyed. Maybe they didn't plan. Maybe they don't
have water on-site... They know that they have a link. In us taking
care of them, hopefully we will be able to continue providing care.
A number of nursing homes also had put plans in place to provide transportation
to the facility for staff and their families. Several nursing homes
reported having facility vehicles available to pick up staff members and
transport them to the facility for work while one (urban) facility reported
supplying staff with taxi vouchers:
In an emergency we'd go pick up people... use our service
vehicles to do that... And we have had staff come in with their children
and have something set up for their kids
We have a system in place where one of our maintenance people... will
go pick up people. Either that or if he's unable to do it... we
have taxi vouchers available.
Other potential solutions for staffing problems included: arranging to trade
staff with other facilities, arranging for additional staff through local
home health agencies and providing financial incentives to critical staff
for working during a disaster. One participant explained his facility's
There's probably five or six facilities within 10 miles of ours.
One of the things we are working on... is trading of staff. If some
of their staff live closer to our facility and can't make it to theirs, 'Come
to ours, bring your family to ours, and we will put you to work!' If
some of our staff live closer to theirs, 'Go there. Bring your family
there.' We are trying to make it as comfortable and easy as possible
for the staff to come in.
In responding to questions about roles that their nursing homes could potentially
play in an emergency, focus group participants emphasized that their ability
to provide resources and services to the community would be highly dependent
on staffing. According to one participant, "Even in a good situation
(in which) you have full staff, there's not excess capacity to, to
triage, to do many other things. Unless people came, you know, unless
there were additional staff that would be mobilized... "
In addition to the concerns about staff adequacy during a time of crisis,
some nursing homes mentioned that State regulations on the number of hours
that clinical staff can work consecutively would be problematic in an emergency. Participants
expressed differing levels of confidence that such regulations would be relaxed
in a disaster.
Nursing homes are worried about running out of pharmaceutical and
other medical supplies in a disaster.
Nursing homes typically receive medication deliveries on a cyclical basis. Monthly
delivery cycles appeared to be the norm. Hence, the length of time
that they could sustain on their existing medication supplies would be highly
dependent on when the disaster occurred in relation to their last delivery.
One participant explained, "If you're right at the end of the
month and waiting for your medications to come in, oh boy, you're in
While most nursing homes mentioned keeping emergency medication supplies
including antibiotics and narcotics on-hand, they explained that these supplies
would not last long. Many participants described stockpiling medications
as a desirable solution, but a number of issues associated with doing so
were raised including rules against stockpiling, the high cost of obtaining
large quantities of medication at a time, reimbursement issues, and concerns
about security if the community became aware that they had such supplies.
According to one participant, "We can't stockpile medications.
We have to get rid of them. As much as I would like to for a disaster, we
can't do it."
Participants stressed that the adequacy of medications and medical supplies
must be taken into account when considering the potential roles that nursing
homes might play in disasters. If, for example, nursing homes are asked
to provide first aid or to care for patients transferred from acute care
facilities, this will have a major impact on how long their limited supplies
last. Many participants expressed concerns about the ramifications
of running out of medications and medical supplies to care for their residents
due to using them to provide care for people from the community or other
The adequacy of fuel supplies to power the generators is a
major concern because power serves a number of important functions in these
All nursing homes reported having generators to provide back-up power in
the event that their facilities lose electricity. When asked how long
they would be able to power their generators without receiving additional
fuel from outside sources, participants' responses ranged from less
than a day to seven days. While nearly all nursing homes reported performing
period checks of their generator's functioning, the generator often
only powered a portion of the facility during the checks. This makes
it difficult to predict the rate at which their fuel supplies would be exhausted
if the whole facility were relying on the generator's power. Another
source of anxiety is whether or not the generator is strong enough to handle
the full load of the facility. One participant told the group that her staff
had been warned at a seminar that:
When they run the generators on the full load for more than a day, most
of them give out because they're not used to it.
One participant told the group that she is worried that the fuel they use
during periodic checks of the generator's functioning will mean that
they would not have enough left if an actual emergency occurred because they
perform checks monthly, but only refuel once every three months.
Participants reported a variety of problems associated with generator failure. Power
is needed to maintain acceptable environmental conditions in the facilities. Nursing
homes may be forced to transfer their residents elsewhere if they are without
heat or air conditioning for an extended period of time during certain parts
of the year. One participant articulated the difficulties in deciding
what temperature warrants undertaking the challenges associated with evacuation:
When you've got 150 residents and you're thinking about moving
them all when the temperature gets to... That's a killer. We make
it 86 degrees and we decide to move, but that's as high as it ever
goes and everybody is comfortable... I have residents who think 90 is
a good temperature.
Power is also necessary to keep some types of special equipment specific
to this population going for a sustained period of time. For example,
oxygen is used for some of the special beds in these facilities. In
the absence of power, oxygen can be provided to patients that need it through
portable oxygen tanks in lieu of the special beds. However, focus group
participants stressed that portable oxygen only lasts a very limited time. One
participant indicated that battery back-up is now available for "some,
but not all" of the medical equipment.
Due to incontinence issues that are common with the geriatric population,
laundry facilities are crucial. One participant pointed out that many facilities
may not have even thought to ensure that their washing machines are hooked
up to the generator. Without regular changes of soiled clothing and bed sheets,
some patients would begin to experience skin breakdown and other such issues.
Also, sanitation could become a problem.
Nursing homes are concerned about having sufficient food and water
Most nursing homes indicated that they could be self-sustaining on their
existing food and water supplies for a period of about three days. While
some nursing homes indicated that they store enough food and water to be
self-sustaining for longer periods, a number of facilities indicated that
their storage space is extremely limited. Given their space restrictions,
storing extra supplies (above and beyond what the State requires) simply
wouldn't be possible for them. To alleviate this problem, a few
facilities distribute water and food supplies to residents for storage in
When their existing supplies are depleted, these nursing homes will be in
competition with the rest of the community to obtain more. Perceptions of
whether a priority list for the replenishment of supplies exists and if so,
where nursing homes would fall on such a priority list varied among focus
group participants. According to one participant, "If a disaster
is somewhat orderly, then it was stated that there might be some priority
to supplies. But, probably not." Another participant indicated
that, "We do have a three-day supply. Anything after that, we would
be pretty much competing with everybody else who wanted to get water. But,
I think we are kind of high on the list."
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