Disaster Behavioral Disaster Behavioral Health Awareness Health Awareness

Training for Health Care Training for Health Care ProfessionalsProfessionals

Copyright © 2004: All Rights Reserved

DEEPDEEPCenterCenter

Disaster Behavioral Health Awareness Disaster Behavioral Health Awareness Training for Health Care ProfessionalsTraining for Health Care Professionals

James M. Shultz MS, PhDJames M. Shultz MS, PhDZelde Espinel MD, MA, MPHZelde Espinel MD, MA, MPHRaquel E. Cohen MD, MPHRaquel E. Cohen MD, MPHJorge R. Insignares MDJorge R. Insignares MDLisa Rosenfeld MPHLisa Rosenfeld MPH DEEP Center University of Miami School of Medicine

Brian W. Flynn EdDBrian W. Flynn EdD Rear Admiral, USPHS (Ret) Assistant Surgeon General (Ret)

Jon A. Shaw MD, MSJon A. Shaw MD, MSDepartment of Psychiatry

University of Miami School of Medicine

Robert J. Ursano MDRobert J. Ursano MDDirector, Center for the Study of

Traumatic Stress Uniformed Services University of the Health Sciences

Joseph A. Barbera MDJoseph A. Barbera MDDirector Institute for Crisis, Disaster, and

Risk Management The George Washington University

Mauricio Lynn MDMauricio Lynn MDAbdul Memon MDAbdul Memon MDS. Shai GoldS. Shai Gold

Jackson Memorial Medical CenterUniversity of Miami School of Medicine

HOSPITAL AS A PATIENT CARE PROVIDER:HOSPITAL AS A PATIENT CARE PROVIDER:

PATIENT CARE STRATEGIES IIIPATIENT CARE STRATEGIES III

DISASTER BEHAVIORAL HEALTH AWARENESS TRAINING FOR HEALTH CARE PROFESSIONALSDISASTER BEHAVIORAL HEALTH AWARENESS TRAINING FOR HEALTH CARE PROFESSIONALS

Patient CareStrategies

Prepare & Mitigate Respond Recover

Pre-event Event Post-event

Plan Train Drill Evaluate Activate Restore Evaluate

Expand surge capacity

Conduct behavioral triage

Conduct behavioral intervention

Manage contamination, isolation, and quarantine

Maintain quality patient care

Support patient families

Meet special population needs

Provide culturally-competent care

Communicate with the public

Patient Care Strategies IIIPatient Care Strategies III

Key Points: Support patient families Provide for special population needs Provide culturally competent care Communicate with the public

Strategy:Strategy:Support Patient Support Patient

FamiliesFamilies

Patient CareStrategies

Prepare & Mitigate Respond Recover

Pre-event Event Post-event

Plan Train Drill Evaluate Activate Restore Evaluate

Expand surge capacity

Conduct behavioral triage

Conduct behavioral intervention

Manage contamination, isolation, and quarantine

Maintain quality patient care

Support patient familiesMeet special population needs

Provide culturally-competent care

Communicate with the public

Goal: Support Patient FamiliesGoal: Support Patient Families

Support family membersSupport family members

of patients by providingof patients by providing

basic needs, timelybasic needs, timely

information flow, andinformation flow, and

Psychological First Aid. Psychological First Aid.

Support Patient FamiliesSupport Patient Families

Following a mass casualty incident, Following a mass casualty incident, hospitals can anticipate a large influx hospitals can anticipate a large influx

of distressed family members.of distressed family members.

Madrid, March 11, 2004Madrid, March 11, 2004In two hours the ER staff had stabilized

and distributed the patients to the corresponding departments

in the hospital. By that time the Emergency Room had the quietness of a battlefield

when the battle is over. But then a nightmare began…

Source: Calcedo-Barba, 2004

…Hundreds of relatives rushed to the emergency room. Since the number was so big they were sent to an auditorium of 400 seats where congresses and scientific meetings take

place. There were around 300 people there at noon. They wanted to know if their relatives and loved ones were in the

hospital… The auditorium was frenzy. Many relatives wanted the names to be repeated since there

could be a misspelling. Some arguments began between the relatives and with the hospital staff. The tension was

high. Others began to shout joyfully when they heard a name. In one case we knew later that it was a mistake and their loved one had really died... Those were hours of anguish

since the relatives began to pilgrim from one hospital to another in search of their loved ones. They came

with pictures of them which they showed to anyone they came across that looked like hospital staff. It was the

same scene that we saw in New York on September 11th…

Source: Calcedo-Barba, 2004

Family Assistance AreaFamily Assistance Area Critical element of hospital preparedness Staffing

Medical professionals Social services professionals Chaplains

Services Basic needs (food, water, rest rooms) Psychological First Aid Credible and current information on patients Counseling support Child care

Family Assistance AreaFamily Assistance Area

Location:Location: remote from treatment areas

Information:Information: written

guide to family support

services

Registration: Registration: family membersfamily members

register names of missingregister names of missing

relativesrelatives

Verification:Verification: family member

identification verifiedSource: Barbera & McIntyre,2003, Jane’s Mass Casualty Handbook: Hospital

Family Assistance AreaFamily Assistance Area

Implement procedures to reach family members when they are off premises

Coordinate with community patient and missing persons tracking systems

Family Assistance AreaFamily Assistance Area“How-to” Example:“How-to” Example:

Jackson Memorial Medical Center, Miami FLJackson Memorial Medical Center, Miami FL

Family Assistance AreaFamily Assistance AreaJackson Memorial Medical Center, Miami FLJackson Memorial Medical Center, Miami FL

Capacity: Up to 1,0001,000 people Large physical space away from ER/Trauma

area Staffing: Psychologist, Social Worker,

Department of Medicine Resident Computers/Photo Albums for patient

identification Public Phones Comfortable Seating Food, Drinks, Rest rooms

Source: Dr Mauricio Lynn, UM-Jackson Memorial Medical Center, 2004

Mental Health

Care Facility

Jackson Jackson MemorialMemorial

Medical CenterMedical CenterMiami, FLMiami, FL

Medical

Red Yellow

FamilyFamilyAssistanceAssistance

AreaArea

Green

Inp

ati

en

tA

mb

ula

tory

Psychiatric Consultation

HospitalTriage

Behavioral Triage/

Psychiatric Screening

Community Community SurgeSurge

Community AgenciesSource: Shaw, 2004

Blue

Family Assistance Center Family Assistance Center (part of hospital cafeteria)(part of hospital cafeteria)Jackson Memorial Medical Center, Miami, FLJackson Memorial Medical Center, Miami, FL

Support BereavedSupport BereavedFamily MembersFamily Members

DefinitionsDefinitions

Bereavement:Bereavement: Fact of loss through death. Grief:Grief: Emotions associated with

bereavement. Bereavement reactions:Bereavement reactions: Any

psychological or physiological response to bereavement.

Mourning:Mourning: The social expression of grief. Anticipatory grief:Anticipatory grief: Emotions experienced

in anticipation of an impending death.Shaw, 2004

Traumatic BereavementTraumatic Bereavement

Responses to sudden and unexpected death

Without anticipatory grief, the shock can be intense and numbing

Acute Grief ReactionsAcute Grief Reactions

Shock Denial Disbelief Unreality Anger – may be

directed at hospital staff

Guilt Agitation

Range of emotions: Sadness Fearfulness

Decreased concentration

Diminished capacity for problem solving

Source: Shaw, 2004

What do relatives want?What do relatives want?

Prompt attention and care for loved one upon arrival at hospital

Timely updates on loved one's condition while in treatment

Direct contact with patient before death Knowledge that patient received prompt

and appropriate treatment Compassionate, unhurried notification of

relative’s death Opportunity for follow-up at later date

Source: Williams et al., 2000

Informing the Family of the DeathInforming the Family of the Death

Communicate the news of death clearly. The chaplain or doctor responsible for the

patient should inform the family directly. Refer to the patient by name. Describe the circumstances of injury and

cause of death. Use plain English*: "is dead" or "died."

* Euphemisms (e.g. “passed away”) can be misinterpreted.

Source: Williams et al. 2000

Most Helpful Actions for Most Helpful Actions for Bereaved FamiliesBereaved Families

1. Provide opportunity to view deceased. Provides concrete evidence that the death has

occurred Allows loved ones to feel the loss as real

2. Respect the culture and customs of family members.

3. Provide both oral and written information about what to do following a death. Family members may be too shocked to absorb verbal information.

Sources: Li et al. 2002; Tye, 1993

Death Practices by ReligionDeath Practices by ReligionReligion Death Practices

Buddhism The body is left as found at death, gently covered with a sheet.

Catholicism Before or after the time of death, a priest should administer the sacrament of anointing of the sick.

Hinduism Death should be peaceful, and the body must be attended until cremation.

Islam After the death, the eyes are closed, the mouth is closed with a bandage, and the arms and legs are straightened.

Judaism The burial is arranged within 24 hours. The body must be attended until the burial. Cremation is not acceptable.

Protestant Determined by specific religious doctrine. Source: Knazik, 2003

The flow and management of The flow and management of patient family members may patient family members may

create one of the greatest create one of the greatest challenges during a disaster challenges during a disaster

or terrorist event.or terrorist event.

Behavioral Health Perspective:Behavioral Health Perspective:Support Patient FamiliesSupport Patient Families

Strategy:Strategy:Provide for Special Provide for Special Population NeedsPopulation Needs

Patient CareStrategies

Prepare & Mitigate Respond Recover

Pre-event Event Post-event

Plan Train Drill Evaluate Activate Restore Evaluate

Expand surge capacity

Conduct behavioral triage

Conduct behavioral intervention

Manage contamination, isolation, and quarantine

Maintain quality patient care

Support patient families

Meet special population needsProvide culturally-competent care

Communicate with the public

Goal: Provide for Special Goal: Provide for Special Population NeedsPopulation Needs

Meet the needs of special Meet the needs of special populations of patients populations of patients including children, the including children, the elderly, and those with elderly, and those with

disabilities. disabilities.

Event-associated patients can be distinguished by age, gender, and

culture. These special populations have special needs.

Special PopulationsSpecial Populations Special populations are distinguished

by age, gender, culture, and unique needs.

Special populations differ on: Disaster effects Disaster vulnerability Coping skills and styles Resources Assessment and intervention approaches

Special PopulationsSpecial Populations

Children and AdolescentsOlder personsRecent immigrants

Persons with:Persons with:

Previous psychiatric diagnosis

History of substance abuse

Physical limitations and disabilities

Special PopulationsSpecial Populations

Persons with:Persons with:

Pre-existing chronic diseases

Immunosuppression

Diseases requiring life-sustaining medications or treatments

Electronically-dependent medical conditions

Children and Children and AdolescentsAdolescents

Differences Between Child and Differences Between Child and Adult Responses to StressAdult Responses to Stress

Children may:Blame themselves for the eventNot understand the eventNot understand cause and effectReact based on developmental

levelReenact the trauma in play

activities

Children and Adolescents: Children and Adolescents: Disaster StressorsDisaster Stressors

Death or separation from loved ones

Destruction of support systems

Disruption of normal routines

Challenge to basic assumptions of safety

Children’s Greatest FearsChildren’s Greatest Fears

Postdisaster—children fear: Separation from family Death of loved ones Injury to loved ones Disaster recurrence Being left alone

Source: State of Florida Family Preparedness Guide, 2003

Older AdultsOlder Adults

Older Adults: Older Adults: Disaster StressorsDisaster Stressors

Barriers to the health care system Degradation of the health care system Stigma associated with help-seeking Lack of financial

resources Multiple loss

effect

Older Adults:Older Adults:Behavior in DisastersBehavior in Disasters

Older adults are slower/less likely to: Evacuate Respond to warnings Acknowledge hazards Seek medical care Use resources Wait in line

Older Adults: Older Adults: Reactions to DisastersReactions to Disasters

Disorientation Fear: loss of control Fear: loss of independence Apathy and withdrawal Impatience and irritability Decreased physical health Feeling too old to start over

Persons with Persons with DisabilitiesDisabilities

Recommendations to Improve Access to Recommendations to Improve Access to Services for Persons with DisabilitiesServices for Persons with Disabilities

Designate patient care representatives to assist persons with disabilities arriving among the casualties from a disaster event.

Provide color-coded bracelets to identify persons with special needs.

Include disabled persons and qualified representatives in hospital disaster drills.

Source: Florida Hospital Preparedness Disability Task Force,2004

Recommendations to Improve Access to Recommendations to Improve Access to Services for Persons with DisabilitiesServices for Persons with Disabilities

Distribute local disaster resource guides to persons with disabilities.

Develop and distribute large-print text, audio, and video materials describing hospital intake, treatment, and discharge practices during disasters.

Source: Florida Hospital Preparedness Disability Task Force,2004

Recommendations to Improve Access to Recommendations to Improve Access to Services for Persons with DisabilitiesServices for Persons with Disabilities

Provide hospital-sponsored education and information for persons with disabilities.

Enhance hospital signage, guideways, and posters to assist persons with disabilities, particularly during disaster events

Source: Florida Hospital Preparedness Disability Task Force,2004

Recommendations to Improve Access to Recommendations to Improve Access to Services for Persons with DisabilitiesServices for Persons with Disabilities

Include protocols to care for “service” animals (such as guide dogs for the visually impaired)

Install video relay devices for deaf and hard of hearing patients and provide sign language services during disasters

Source: Florida Hospital Preparedness Disability Task Force,2004

Recommendations to Improve Access to Recommendations to Improve Access to Services for Persons with DisabilitiesServices for Persons with Disabilities

Identify sources of assistive devices to replace equipment that is contaminated or destroyed in a terrorist attack.

Source: Florida Hospital Preparedness Disability Task Force,2004

Meeting the needs of special Meeting the needs of special populations, including populations, including

children, elderly patients, children, elderly patients, and persons with and persons with

disabilities, requires special disabilities, requires special capabilities and proactive capabilities and proactive

advocacy.advocacy.

Behavioral Health Perspective:Behavioral Health Perspective:Provide for Special PopulationsProvide for Special Populations

Strategy:Strategy:Provide Culturally Provide Culturally Competent CareCompetent Care

Patient CareStrategies

Prepare & Mitigate Respond Recover

Pre-event Event Post-event

Plan Train Drill Evaluate Activate Restore Evaluate

Expand surge capacity

Conduct behavioral triage

Conduct behavioral intervention

Manage contamination, isolation, and quarantine

Maintain quality patient care

Support patient families

Meet special population needs

Provide culturally-competent careCommunicate with the public

Goal: Provide Culturally Goal: Provide Culturally Competent CareCompetent Care

Provide quality care that is Provide quality care that is responsive to the cultural responsive to the cultural

needs of diverse needs of diverse subgroups of patients.subgroups of patients.

Cultural ConsiderationsCultural Considerations CultureCulture influences how individuals perceive

and interpret traumatic events. CultureCulture influences how they, their families,

and their communities respond. Providing care for survivors must be done

in a culturally competentculturally competent manner.

Cultural Groups: Cultural Groups: Disaster StressorsDisaster Stressors

Immigration status Language difficulties Lack of insurance

Limited finances Discrimination

Difficulty accessing disaster services

Cultural DifferencesCultural Differences

Cultural differences:Cultural differences: Definition of disasterExpression of griefAcceptance of help Use of support Role of faith Cultural differences

in response to loss

Cultural Competence Applied Cultural Competence Applied to Disaster Behavioral Healthto Disaster Behavioral Health

Cultural competenceCultural competence

is the ability to understand

and respond effectively

to the cultural and linguistic needs

of individuals and families

most affected by a disaster.

Source: Project Liberty, 2002

Disaster Responders: Disaster Responders: Culturally Competent ConductCulturally Competent Conduct Know the culture Be respectful and

well informed Be alert to

personal biases Admit personal

limitations to understanding culture

Disaster Responders: Disaster Responders: Culturally Competent ConductCulturally Competent Conduct

Recognize the importance of culture and respect diversity

Understand the cultural expression of distress

Respect the need for ritual and customs

Challenge to Challenge to Culturally Culturally

Competent Care:Competent Care:Anthrax, 2001Anthrax, 2001

Case 5: Biological WeaponsCase 5: Biological WeaponsSite:Site: US Mail System, 2001 Perpetrator:Perpetrator: Domestic terrorist ?Agent:Agent: Modified anthrax

Fall 2001 Anthrax Fall 2001 Anthrax Outbreak via the Outbreak via the U.S. MailU.S. Mail

Release of several grams of anthrax spores in 7 mailed envelopes

BioterrorisBioterrorismm

Case 5

BioterrorismBioterrorism

5 deaths 18 nonfatal infections 30,000 employees

treated with antibiotics

Hoarding of Ciprofloxacin

Fall 2001 Anthrax Fall 2001 Anthrax OutbreakOutbreak

Case 5

BioterrorismBioterrorism

Shutdown of:

Brentwood mail processing center

US House of Representatives Hart Senate

Office Building

Supreme Court

HHS Building

Fall 2001 Anthrax Fall 2001 Anthrax OutbreakOutbreak

Case 5

BioterrorismBioterrorism

HAZMAT calls: 60,000 excess calls

nationwide in first 2 weeks

In this outbreak, fear was “contagious”

“Anthrax anxiety” was common

“Contagious somatization”: anxious

search for physical symptoms

suggesting contagion

Fall 2001 Anthrax Fall 2001 Anthrax OutbreakOutbreak

Case 5

BioterrorismBioterrorism

Accusations of differential, discriminatory

treatment of postal workers relative to

government office workers

Fall 2001 Anthrax Fall 2001 Anthrax OutbreakOutbreak

Case 5

Lessons learned:

1.Even a small-scale event has

cascading effects.

2.Terrorism cuts along the fault lines of society

Source: Ursano, 2003

Since terrorism strikes along Since terrorism strikes along the fault lines of society—the fault lines of society—

maintaining culturally maintaining culturally competent and equitable competent and equitable care must be specifically care must be specifically

prioritized.prioritized.

Behavioral Health Perspective:Behavioral Health Perspective:Provide Culturally Competent CareProvide Culturally Competent Care

Strategy: Strategy: Communicate Communicate with the with the PublicPublic

Patient CareStrategies

Prepare & Mitigate Respond Recover

Pre-event Event Post-event

Plan Train Drill Evaluate Activate Restore Evaluate

Expand surge capacity

Conduct behavioral triage

Conduct behavioral intervention

Manage contamination, isolation, and quarantine

Maintain quality patient care

Support patient families

Meet special population needs

Provide culturally-competent care

Communicate with the public

Goal: Communicate with Goal: Communicate with the Publicthe Public

Communicate effectively with Communicate effectively with patients, staff, and public to patients, staff, and public to maximize safety, security, maximize safety, security,

and quality care.and quality care.

• Conflicting reports• Inaccurate information

• False reassurance• Exaggerated fear messages

• Delays in communicating the facts

Communicating RiskCommunicating Risk

Source: Pilch, 2004

Increase anxiety and decrease public trust

Increase fears and rumors

Communicating RiskCommunicating Risk

Behavioral Goal:Behavioral Goal:

“Clear, consistent, accessible, reliable,

and redundant information

(received from trusted sources)

will diminish public uncertainty

about the cause of symptoms

that might otherwise prompt persons

to seek unnecessary treatment.”Source: Benedek et al., 2002

““Better than any medication Better than any medication that we know, that we know, informationinformation

treats anxiety during crisis.”treats anxiety during crisis.”

Source: Saathoff et al. 2002

General GuidelinesGeneral Guidelines Tell the truth as it is known,

when it is known. Explain what is being done

to deal with the problem. Avoid withholding bad news

or disturbing information. Be forthright about what is

not known. Provide practical guidance

for citizen protection.

Sources: Glass et al. 2002; Pilch, 2004

Information is a “life blood” Information is a “life blood” during disasters. Effective during disasters. Effective communication can guide communication can guide

citizens to seek appropriate citizens to seek appropriate health care and take self-health care and take self-

protective actions.protective actions.

Behavioral Health Perspective:Behavioral Health Perspective:Communicate with the PublicCommunicate with the Public