Natural Disaster Mitigation, Preparedness, Response, and Recovery
The lack of predictability and the potential long-term effects of a natural disaster can cripple an unprepared healthcare entity. The four phases of emergency management―mitigation, preparedness, response, and recovery―can be used as a framework to decrease vulnerabilities, improve response, and speed return to normal operations after a natural disaster.
Below you’ll find strategies and resources for improving patient safety and reducing liability risk in the event of a natural disaster, which can be integrated into a general emergency preparedness and management plan.
Natural disaster mitigation strategies are unique in that they focus on reducing the severity of the impact, instead of preventing the hazard. A risk assessment should provide the basis for mitigation strategies to improve readiness, response, and recovery.
- Identify mitigation activities required by law, accreditation by professional organizations (e.g., Joint Commission Emergency Management Elements of Performance), and participation in government programs (e.g., Centers for Medicare and Medicaid services (CMS) Emergency preparedness rule).
- Based on the risk assessment, prioritize facility-specific mitigation measures, such as redundancy of power, communications, and data management systems (e.g., obtaining uninterruptible power supplies (UPS) and emergency standby generators for critical equipment); installing water-tight subbasement doors; reinforcing tornado/earthquake safe rooms; installing window film to prevent injuries from shattered glass; etc.
- FEMA has various Hazard Mitigation Assistance grant programs, including benefits for hospital power generators.
- Review insurance policies to determine whether they adequately cover potential losses.
Preparedness involves a continuous process of planning, training, testing, evaluating, and correcting to ensure the best disaster response and recovery possible. The cycle of preparedness begins with risk assessment and results in a plan. The plan should include training that helps ensure everyone knows their roles and responsibilities and can perform their designated duties in response to a disaster. Due to the nature of natural disasters, preparedness and mitigation strategies may overlap.
- Conduct a risk assessment (also referred to as a hazard vulnerability analysis (HVA)) to identify potential geographic vulnerabilities in practice locations. For example, geographic vulnerabilities include hurricanes in coastal areas, earthquakes on the west coast, and blizzards and ice storms in increasingly expanding areas across the United States.
- Prepare for each vulnerability identified in the risk assessment. For example, have plans, agreements, protocols, and policies in place for:
- Patient evacuation to another facility to continue care in the event of facility destruction, patient transfer to an alternate care facility or sheltering in place.
- Increased staffing immediately after a natural disaster, for example, granting temporary privileges to clinicians.
- Alternative means of meeting essential building utility needs, for example, maintaining healthcare operations during power outages, including protecting refrigerated vaccines and maintaining water supply.
- Create a crisis management team and designate a command center.
- Develop an effective emergency response plan, which may include an Emergency Operations Plan (EOP) and a Continuity of Operations Plan (COOP), for Joint Commission accredited organizations.
- Review and update plans on a regular basis.
- Develop a business continuity plan.
- Develop and implement disaster preparedness training programs.
- Plan, test, and simulate the most likely disaster scenarios that may occur.
- Review the results of simulations and facility response to identify opportunities for improvement.
- Develop a plan for communication with stakeholders.
Maintain a contact list for the supplies; services; and community, state, and federal resources that will be necessary during response and recovery from a disaster.
- Include processes for patient identification and family notification in an emergency.
- Appoint and train a spokesperson and backup spokesperson.
- Be prepared to use social media.
Additional Mitigation and Preparedness Resources and Toolkits
Emergency Preparedness Rule – CMS Emergency Preparedness Rule
Preparedness Planning for Your Business – Ready.gov - Emergency Response Plan
About the Hospital Preparedness Program – HHS – Public Health Emergency
2017 – 2022 Health Care Preparedness and Response Capabilities – ASPR’s Hospital Preparedness Program (HPP) – Guidance and technical assistance to help healthcare coalitions and their members.
Hospital Preparedness Checklists and Tools – California Hospital Association
Response is the third phase of managing an emergency and includes those activities immediately before an impeding threat, during, and after a disaster impact and addresses the immediate and short-term effects. It usually focuses on providing emergency medical treatment to those affected, minimizing secondary impacts, and limiting the negative effects of the situation.
A responsive organization maintains an organized structure under emergency conditions. It also conducts information management, emergency decision-making, incident planning, actions to implement decisions, and coordination of resources.
Consider activating a systems-based response with the following in mind.
- Protect personnel, current patients, visitors
- Provide the best available medical care for responders, victims/patients, and affected families
- Protect critical infrastructure, facilities, vital records, and other data
- Manage regulatory compliance
- Restore essential services
An effective incident command structure triggers notification to key personnel and the incident management team. The Federal Emergency Management Agency (FEMA) has education and training on incident command structures available at https://training.fema.gov/nims/ .
The National Institute for Occupational Safety and Health (NIOSH) has created a document communicating key messages associated to the multiple hazards related to storms, floods and hurricanes. The document is available for employers, emergency response and recovery workers, and volunteer at https://www.cdc.gov/niosh/topics/emres/pdfs/NIOSH-Emergency-Responder-Key-Messages-Update-2021_508.pdf.
Typical patient care concerns following a disaster include follow-up, transfers, and medication management.
- As you are able, review schedules to determine which patients have acute issues and upcoming or missed appointments in the outpatient hospital departments and the on campus medical office building. Attempt to contact patients, prioritizing by urgency.
- Document all ongoing communication and resulting action and status.
- Document where you instructed patients to go (e.g., shelter, clinic, urgent care, emergency department), or if other arrangements were made (e.g., home health visit, telehealth visit).
Patients may need replacement prescriptions for medications or they may be due for refills. You may also encounter displaced patients who are seeking care in your community.
- Handle the prescription management process carefully and in compliance with law and regulation. The State Board of Pharmacy for individual states can be a reliable resource in a state of emergency.
Documentation Accompanying Hand-Offs/Transfers
If your facility is required to evacuate patients, tracking those patients is a key risk management measure. Documentation to accompany patients should ideally include critical information to support continuity of care and treatment, such as:
- Patient name and date of birth
- Problem list
- Emergency contact
- Copy of Medication Administration Record (MAR)
- Copy of most recent discharge or care summary
- Copies of latest lab reports
- Primary care physician information
Medical Record Documentation During Evacuation or Hand-Off
Considerations for medical record documentation during evacuation or hand-off may include the following.
- Evacuation/triage level
- Patient condition
- Availability of medical record
- Disposition (e.g., home, shelter, transfer)
- Accepting location and physician
- Arrival confirmation
- Medications, personal belongings, equipment accompanying patient
- Times (departure, arrival)
- Family notification
- Communication with local, regional, and federal authorities
Security and Privacy of Medical Information during Response
While the HIPAA Privacy Rule is not suspended during a public health or other emergency, if the Secretary of HHS declares a public health emergency in your state, then HHS may exercise its authority to waive sanctions and penalties associated with HIPAA violations.
Visit the American Health Information Management Association (AHIMA) website for additional information on Complying with the Privacy Rule during a Disaster Part 1 and Complying with the Privacy Rule during a Disaster Part 2.
Social Media Response
- Consider having a designated person update social media to keep the public notified as circumstances change.
- Disseminating accurate, timely, and appropriate updates can help calm both patients and family members as well as reduce overall panic.
- Proper monitoring of social media and response information may dispel rumors and the spread of misinformation.
Power Failures and Staffing Shortages
- Without electricity, healthcare organizations may need to use a numbering system to track patients, their diagnoses, and treatment.
- Healthcare organizations may need increased staffing immediately after a natural disaster because some staff may be unable to continue working. Organizations may have to grant temporary privileges to providers during a disaster. Natural disasters can also have a larger impact on your organization’s staff since they may also have lost personal property, homes, or loved ones.
- The Department of Homeland Security provides general guidelines and tips for preparing for and responding to a power outage.
Accreditation Bodies and Payor Resources
Core EP Rule Elements Resources - Centers for Medicare and Medicaid Services.
Emergency Management Resources - The Joint Commission.
The last phase—recovery—is the resumption of normal operations and services, begins simultaneously with response actions, and includes those activities to assess—including the need to notify the appropriate insurance carriers—manage, and facilitate recovery.
Many healthcare entities may suffer water and wind damage during a natural disaster; some may have standing water for an extended period due to flooding. Building structures, equipment, and supplies may be heavily contaminated with microorganisms such as mold, mold spores, and bacteria.
Before reopening, healthcare entities must be evaluated to determine if the facility is damaged beyond repair and must be condemned or if the extent of the damage is such that the facility may be restored, repaired, and reopened.
Disaster Site Management
- A full debriefing is needed to detail what supplies have been depleted, staff issues, mutual agreements honored, supply management issues, and what repairs are necessary to continue business operations. For example, if the area of the organization’s pharmacy is flooded, mold and cleaning remediation will be necessary to make the structure useable. Pharmacy inventory will need to be replaced.
- Resources and information for infection control considerations for reopening healthcare facilities due to extensive water and wind damage may be located on the CDC website.
- The National Institute for Occupational Safety and Health (NIOSH) provides guidance on the management of chemical structural hazards, asbestos, carbon monoxide, heat stress, confined spaces and electrocution.
Damaged or Destroyed Medical Records
Many healthcare facilities and physician offices will be trying to recover and restore damaged paper and electronic records in the weeks and months following the wildfires. Before investigating potential damage to paper medical records:
- Ensure the storage location is safe to enter.
- Call your general liability/property insurer for directions and recommendations.
- Execute business associate agreements with any vendor hired to help recover PHI.
Best Practice Considerations for Handling Water Damaged Records
- Handle them as little as possible and keep them from molding.
- Mold starts to grow quickly—within two to three days—so it is important to act as soon as possible.
- Reduce the temperature and humidity and increase the circulation in the record storage area.
- If a professional document drying company cannot be contacted within 48 hours, place the records in a freezer.
- Do not open or clean the records.
- Pack records tightly to avoid movement during transport.
- Do not thaw the records without obtaining professional advice.
Document Drying/Restoration Resources
National Resource Guide for Disaster Preparedness (PDF) - Conservation Center
Emergency Salvage of Flood Damaged Documents
Emergency Salvage of Wet Books and Records
After the Flood: Mold Specific Resources – ASPR TRACIE
Preventing Occupational Respiratory Disease from Exposures Caused by Dampness in Office Buildings, Schools, and Other Nonindustrial Building – NIOSH
Reconstructing the Medical Record
State Medical Boards require a physician to maintain adequate and accurate records. Failure to do so may represent unprofessional conduct. If you cannot salvage medical records or otherwise reconstruct them via electronic data recovery, you should recreate them to the best of your ability.
Approach the various other entities that are storing your patients’ PHI in their own databases and record-keeping systems. For example, pharmacies, consultants, prior treating physicians, third-party insurers, transcription services, and hospitals most likely have PHI they can provide. The following strategies can facilitate the reconstruction process:
- Inform patients in writing of their PHI destruction.
- Include the date and circumstances.
- Describe attempts to reconstruct their records.
- Send the patient a history form.
- Invite the patient to contact you to provide additional information.
- Keep a copy of the patient record in the patient’s new file.
- Date the reconstructed record with the current date.
- Identify the record as reconstructed PHI so there is no question as to whether the record is reconstructed or original.
- Contact third party insurers as soon as possible to determine whether they require attestation forms.
Documentation of Medical Record Destruction/Recovery/Reconstruction Efforts
- Describe the event (date, severity, duration, etc.).
- Describe the loss of PHI.
- Construct a log of damaged or destroyed records.
- Include photograph/video records of the damage and copies of property insurance claims documentation.
- Describe efforts to reconstruct PHI.
- Enter a description of the event and reconstruction efforts into reconstructed patient record.
- If affected PHI is requested, include documentation of PHI damage and recovery efforts with your response to the PHI request.
Hurricanes and their impacts present significant challenges to physicians and healthcare entities in the affected areas. As hurricanes make landfall, they often bring heavy rain and strong winds to the affected areas and surrounding regions.
We’ve collected references and strategies for preparing for the possibility of hurricane and flood-related issues that physicians, dentists, and healthcare entities are expected to encounter.
Hurricane and Flood Resources
Hurricane Risk Mitigation and Preparedness Checklist – ProAssurance
Tips about Medical Devices and Hurricane Disasters – FDA
Practice Preparation Checklist for Hurricane Season - DAS Health
Active Hurricanes, Cyclones, and Disturbances – National Hurricane Center and Central Pacific Hurricane Center
Flood Preparedness and Response – OSHA
DHS Ready Check Hurricane Readiness Checklist
Ready Business Hurricane Toolkit (PDF)
Ready Business Inland Flooding Toolkit (PDF)
Public Health Emergency Resource for Professionals
US Department of Labor OSHA Hurricane Preparedness and Response
CDC Post-Hurricane Safety Advice for Healthcare Professionals
Wildfires can have a devastating impact on physicians and healthcare organizations as they strive to deliver safe patient care. Administrators and providers also need to be concerned about having complete medical records and ensuring that access to records is handled appropriately and protects patient confidentiality.
Depending on the circumstances and your current resources and capabilities, you may be unable to accomplish activities as you would during normal daily operations. The main objective is to provide safe and appropriate care to your patients.
Wildfires - The Centers for Disease Control and Prevention (CDC)
U.S. Department of Health and Human Services (HHS), Assistant Secretary for Preparedness and Response (ASPR), Technical Resources, Assistance Center, and Information Exchange (TRACIE). EXCHANGE Newsletter, Issue 10, 2020, Lessons learned from recent wildfires, including evacuating and receiving patients, and preparing for power outages.
Although California is the state most likely associated with earthquakes, other states including Alaska, Oregon, and Washington are also at increased risk. In addition to potential injuries and business interruption associated with structural failure, earthquakes can cause fires, tsunamis, landslides, and avalanches. Therefore, many of the mitigation, preparedness, response, and recovery strategies associated with other natural disasters can also be applied to earthquake plans.
Earthquake Preparedness for Community Clinics and Health Centers – California Primary Care Association and National Association of Community Health Centers
Earthquake Drills for Healthcare Organizations – Great ShakeOut