536927
research-article2014
NCPXXX10.1177/0884533614536927Nutrition in Clinical PracticeTrento and Allen
Invited Review
Hurricane Sandy: Nutrition Support During Disasters Laura Trento, MS, RD, CNSC1; and Sarah Allen, MS, RD, LDN2
Nutrition in Clinical Practice Volume 29 Number 5 October 2014 576–584 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614536927 ncp.sagepub.com hosted at online.sagepub.com
Abstract Natural disasters and weather-related emergencies can strike at a moment’s notice. Individuals with chronic health conditions and other special needs are especially vulnerable. Basic services such as water, electricity, gas, and telephone service may not be available. Home parenteral and enteral nutrition consumers are at a serious risk as they depend on clean water and power for nutrient delivery. Creating a comprehensive emergency preparedness plan is imperative for both the home parenteral and enteral consumer and home care provider to ensure that special needs are met. Home care providers can assist home parenteral and enteral consumers in disaster and emergency planning. (Nutr Clin Pract. 2014;29:576-584)
Keywords nutritional support; home parenteral nutrition; disasters; emergencies; risk management; home care services; enteral nutrition; parenteral nutrition
Natural disasters and weather-related emergencies can strike quickly and without advanced warning, including earthquakes, tornadoes, avalanches, landslides, floods, and forest fires. Others, such as hurricanes and snowstorms, provide some degree of advanced warning. These disasters can have a devastating effect on individuals and the community at large. Basic services such as water, electricity, gasoline, and telephone service may not be available. Mandatory and forced evacuation may be necessary or confinement to the home. Individuals with chronic health conditions and other special needs are especially vulnerable. Disasters and weather-related emergencies present a serious challenge to these individuals. Approximately 7 million individuals in the United States receive homecare from 17,000 homecare providers because of acute illness, chronic conditions, permanent disability, or terminal illness.1 Technological advancement has permitted many chronic health conditions to be managed in the home. Ventilators, oxygen therapy, peritoneal dialysis, feeding pumps, intravenous (IV) fluids, and parenteral nutrition (PN) are few examples of advancements that have contributed to the expansion of homecare.2,3 Individuals dependent on home parenteral and enteral nutrition (HPEN) are at increased risk because of their dependence on electricity and clean water. In addition, they depend on homecare providers for delivery of enteral formula, home parenteral solutions, and administration supplies. This dependence makes being prepared for a disaster a shared responsibility. Homecare providers should have an emergency preparedness plan (EPP) in place for each type of disaster. The plan needs to be reviewed frequently in order for the homecare provider to meet the needs of the HPEN consumer.4 The HPEN consumer should take an active role in planning for emergencies to ensure the plan meets the consumer’s specific needs. Involving the consumer in the
planning process may also help him or her feel more confident should disaster strike. We present clinical and operational experience during one such weather-related emergency: Hurricane Sandy. Challenges in the provision of nutrition support services to the HPEN consumer during the aftermath of the storm are presented. A review of emergency preparedness plans for the homecare provider and HPEN consumer is discussed.
The Impact of Hurricane Sandy Hurricane Sandy (officially referred as post–tropical cyclone Sandy) was the most destructive hurricane of the 2012 Atlantic hurricane season.5 Unofficially known as Superstorm Sandy or Frankenstorm, it began as a tropical storm in the Caribbean on October 22, 2012. It made landfall as a hurricane in Jamaica on October 24, 2012. Temporarily weakened to a tropical storm after passing over the Bahamas on October 27, 2012, it regained strength as a category 1 hurricane before turning toward the eastern U.S. coast (Table 1).5,6 Landfall in the United States occurred at 8 pm on October 29, 2012, just north of Atlantic City, New Jersey. Although it was a category 2 storm as it approached the coast of the northeastern United States, the storm became the largest Atlantic hurricane on record with the winds spanning out a diameter of From 1Coram Specialty Infusion Services, Totowa, New Jersey, and 2 Coram Specialty Infusion Services, Jackson, Tennessee. Financial disclosure: None declared. This article originally appeared online on June 25, 2014. Corresponding Author: Laura Trento, MS, RD, CNSC, Coram Specialty Infusion Services, 11 Commerce Way, Totowa, NJ 07512, USA. Email: [email protected]
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Table 1. Saffir-Simpson Hurricane Scale. Scale Number (Category)
Sustained Winds, mph
1
74–95
2
96–110
3
111–129
4
130–156
5
157 or higher
Damage
Storm Surge, ft
Minor damage to exterior of homes Toppled trees Damaged power lines, power outages Extensive damage will occur Major damage to exterior of homes Uprooting small trees, blocked roads Power outages for days to weeks Devastating damage will occur Extensive damage to exterior of homes Many trees uprooted, many blocked roads Limited availability of water and power Catastrophic damage will occur Loss of roof and/or exterior walls Most trees uprooted and most power lines down Residential roads cut off Power outages for weeks to months Catastrophic damage will occur High percentage of homes destroyed Major roads cut off by fallen trees and power lines
4–5
Figure 1. Satellite image of Hurricane Sandy near landfall on October 29, 2012. Source: U.S. National Oceanic and Atmospheric Administration.
1100 miles (Figure 1).5 The impact of the storm was felt across more than a dozen states. The entire East Coast from Florida to Maine was affected. The densely populated states of New York and New Jersey were severely affected with heavy rain, strong winds, and record storm surges (Table 2).5,6 New York City (NYC), surrounding suburban communities, and Long Island were severely affected. Life-threatening
6–8
9–12
13–18
18 or more
flooding occurred in the NYC subway system; all road tunnels entering Manhattan, New York (with the exception of the Lincoln Tunnel); and many coastline communities. Numerous homes and businesses were destroyed by fire, including more than 100 homes in Breezy Point, Queens, New York.5 Many parts of NYC were without power for several days. Numerous NYC hospitals and nursing homes required closure or sudden evacuation. In preparation for the storm, mandatory evacuations of coastal communities of Long Island, lower Manhattan, Staten Island, Brooklyn, and Queens were implemented. All subway, bus, and commuter rail service was suspended by the evening of October 28, 2012. All bridges, tunnels, and ferry service were shut down as of the afternoon of October 29, 2012. All flights in and out of the major New York and New Jersey airports were cancelled.5 The effects of Hurricane Sandy on New Jersey were devastating. The New Jersey shoreline suffered the most severe winds (as high as 90 mph) and surf. Mantoloking, New Jersey, a small oceanfront community, suffered severe “wash over,” with the creation of 2 temporary inlets (Figure 2).5 More than 2 dozen homes were completely removed from their foundation. Many homes and businesses in the seaside communities were destroyed by storm surge, leaving up to 4 feet of sand in streets, rendering them impassable.5 Historic boardwalks, amusement parks, and marinas along the New Jersey shoreline were destroyed (Figure 3).5 Communities along the west Hudson waterfront (across the Hudson River from NYC) were flooded by storm surge. Half the city of Hoboken, New Jersey was flooded. Numerous fire stations in both New York and New Jersey required evacuation. Communities in other areas of New Jersey required forced
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Table 2. Hurricanes and Important Definitions. Weather-Related Emergency Tropical storm Hurricane Tropical storm warning Tropical storm watch Hurricane warning Hurricane watch Storm surge
Definition A tropical cyclone with maximum sustained surface wind speed of 39–73 mph. A tropical cyclone with maximum sustained surface wind speed of 74 mph or more. An announcement that tropical storm conditions are expected somewhere within a specified area within 36 hours. An announcement that tropical storm conditions are possible within a specified area within 48 hours. An announcement that hurricane conditions are expected within a specified area. Hurricane warnings are issued 36 hours in advance of the anticipated onset of tropical storm force winds. An announcement that hurricane conditions are possible within a specified area. Hurricane watch is issued 48 hours in advance of the anticipated onset of tropical storm force winds. An abnormal rise in sea level accompanying a hurricane or other intense storm and whose height is the difference between the observed level of the sea surface and the level that would have occurred in the absence of the cyclone. Storm surge is estimated by subtracting the normal or astronomic high tide from the observed storm tide. A storm surge can reach heights of well over 20 feet and can span hundreds of miles of coastline.
Figure 2. Aerial view during army search and rescue mission in Mantoloking, New Jersey, on October 30, 2012. Source: U.S. Air Force.
evacuation and rescue after a berm and river overflowed due to storm surge. There were reports of up to 5 feet of water in the streets of Little Ferry and Moonachie, New Jersey.5 On the morning of October 30, 2012, more than 2 million households and businesses in New Jersey were without power. As of November 9, 2012, a total of 265,000 homes and businesses remained without power. More than 346,000 homes were destroyed or damaged, with 22,000 homes completely inhabitable.5 Most gas stations in NYC and New Jersey were closed because of power shortages and depleted fuel supplies. Sixty percent of the gas stations in New Jersey remained closed as of November 2, 2012. Odd-even rationing (based on license plate numbers) of gas purchases was implemented by the governor of New Jersey to help prevent fuel shortages and reduce long waiting times.5 In total, some 4.7 million households in 15 states were without power. Some remained without power for up to 2 weeks after the storm. Drinking water in several New Jersey and New York communities was deemed unsafe. Transportation systems in both New Jersey and New York were severely affected. Restoration of full rail service from Hoboken into Manhattan took until January 2013 to complete. As of April 2013, a total of 39,000 families in New Jersey were still unable to return to their homes.5 Hurricane Sandy remains one of the most costly natural disasters in the United States. In NYC alone, the economic loss was $19 billion; in New Jersey, the cost was estimated at $30 billion (Table 3).5
Planning and Preparing for Emergencies for the Professional Figure 3. Aerial view of damage to Casino Pier in Seaside Heights, New Jersey. Source: New Jersey National Guard.
During the aftermath of a natural disaster or weather-related emergency, access to electricity and safe water may be limited or not available. Telephone services may be out and roads and
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Table 3. Costliest U.S. Atlantic Hurricanes. Rank
Hurricane
1 2 3 4 5 6 7 8 9 10
Katrina Sandy Ike Andrew Wilma Ivan Irene Charley Rita Frances
Season
Damage
2005 2012 2008 1992 2005 2004 2011 2004 2005 2004
$108 billion $65 billion $29.5 billion $26.5 billion $21 billion $18.8 billion $15.6 billion $15.1 billion $12 billion $9.51 billion
Cost refers to total estimated property damage.
bridges impassable. Hospitals and emergency rooms may be overcrowded or completely closed. HPEN consumers could experience disruption of needed support services. Disruption of services may lead to serious adverse effects. As HPEN consumers rely on power and safe water to administer prescribed therapy, planning in advance of an emergency is imperative. Emergency preparedness planning is a shared responsibility. Homecare providers need to provide their expertise to help guide and support HPEN consumers.4 The objective of an EPP for the homecare provider is to (1) ensure safety of consumers and employees, (2) minimize any interruption of services, and (3) prepare contingency plans or designate a back-up provider. The priority during an emergency situation is the safety of human life while preserving property, equipment, and records. An organization’s EPP plan should incorporate a patient risk assessment tool. The goal of the tool would allow the homecare provider to identify individuals at risk for hospital admission if homecare services were to be interrupted. The tool would help homecare providers anticipate the needs of their patients.7 Storm-related emergencies and disasters with advanced warning would allow sufficient time to review patient lists and prioritize care. Standardization of risk levels has been recommended for homecare providers (Table 4).7 Categories for assessing risk could include level of care needs, clinical diagnosis, caregiver support, and timeframes for visits.7 In the case of the home infusion provider, therapy type may be used in assessing risk level. Designing systems that can print or transmit lists of high-risk patients to emergency responders is suggested.7 Advanced warning of a weather-related emergency or disaster will allow homecare providers to contact HPEN consumers prior to the event. Contact should include an inventory of supplies in the home (including enteral formula and home PN solutions), which will identify any urgent need for delivery of supplies. Consumer need for a homecare nursing visit can also be assessed. The homecare provider should inquire if the HPEN consumer requires or may require mandatory evacuation. Alternate address and telephone number should be obtained in
case of evacuation or anticipation of loss of telephone service; an alternate number for contact (designated back-up provider or message center) should also be provided to the HPEN consumer. For the homecare provider that services home enteral nutrition (HEN) consumers, inventory of equipment and supplies available locally and what may be readily obtained from regional or national warehouses should be conducted.4 HEN consumers who require use of a feeding pump for infusion of the enteral product will need to be identified. In the advent of a power failure, an alternate method of feeding may be necessary; education on an alternate feeding method will be required.4 Consumers should be contacted by their homecare provider within the first 12–48 hours of the emergency condition with priority of contact based on the patient risk assessment. Consumers should be assessed for the following: (1) safety and security of current location, (2) days of supplies (including enteral formula and home PN solutions) remaining in the home, (3) access to electricity and safe water, and (4) need for homecare nursing visit. If a consumer requires evacuation, verification of the evacuation destination will be required. For HEN consumers who require a feeding pump and are without power, the provider needs to assess gravity bag availability and need for education by a registered dietitian.7
Planning and Preparing for Emergencies for the Consumer “Be prepared” is one of the best mottos for an HPEN consumer.8 Planning in advance of an emergency will ensure that the consumer’s unique needs are met and therapy can continued uninterrupted. HPEN consumers’ EPP involves knowing the risks, making a plan, and having an emergency supply kit.9 Consumers will need to determine if they can remain safely at home or will require evacuation. Evacuation may be advised or mandatory. The amount of time required to leave will depend on the impending emergency. Usually, 1–2 days of advanced notice is provided prior to a storm. In some circumstances, sudden evacuation or rescue is required. In that case, there will be limited time to gather even bare necessities. Evacuation may be by car, ambulance, military vehicle, or air transport. Temporary shelter may involve staying with friends or relatives, commercial lodging, or a mass care facility operated by disaster relief groups.6 HPEN consumers should consider wearing a medical alert bracelet that is registered with a medical alert company or carry a USB flash drive that will allow medical personnel easy access to medical information.9 An emergency contact list should be prepared and include names and contact information for designated family and friends, physicians, and pharmacy and homecare providers (infusion provider, durable medical equipment provider, and nursing provider).10 Consumers should consider entering the emergency contact list into their personal cell phone contacts as ICE (in case of emergency).9 A
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Table 4. Assessment for Patient Risk. Risk Level
Needs Assessment
High risk or high priority
Requires uninterrupted services Requires life-sustaining equipment Needs regularly scheduled RN visit
Medium risk or medium priority
No immediate threat to life May suffer adverse effect if homecare service interrupted
Low risk or low priority
Would not suffer major adverse effect if homecare services interrupted
Therapy Type Inotropes Ventilator dependent Oxygen dependent Lack of caregiver Complex wound care HPEN Pain management IV hydration IV antibiotics Caregiver available
HPEN, home parenteral and enteral nutrition: IV, intravenous; RN, registered nurse.
Table 5. Health Information Card. •• •• •• •• •• •• •• •• •• •• ••
Address and phone number Emergency contact list Physician name and phone number Pharmacy name and phone number Homecare provider name and phone number (infusion, DME, nursing) Blood type Allergies Special equipment needs Medication list (list dose, frequency, and reason for use) Disabilities and other medical conditions Copy of current HPEN prescription
DME, durable medical equipment; HPEN, home parenteral and enteral nutrition.
copy of the emergency contact list should be kept in the consumer’s emergency supply kit. HPEN consumers can contact their utility company as part of their EPP. Many utility companies keep a list and map of locations of power-dependent customers.6 A letter from the HPEN consumer that contains (1) name and address of the person with specific medical needs, (2) physician’s registration number (National Provider Identifier number), (3) signature of the physician, and (4) explanation of the medical need for power to run the pump and refrigeration to maintain temperature of home PN solutions will need to be on record with the utility company prior to the event.10 A health information card should be created (Table 5).9,10 The Packet for Travel and Hospital Admissions, available through the Oley Foundation, can be used as a template. The packet is meant to help consumers communicate medical needs and history to hospital personnel. It can be quite useful during emergency situations.11 Consumers should keep a copy of their health information card or Packet for Travel and Hospital Admissions in the emergency supply kit. Assembling an emergency supply kit in advance will allow the HPEN consumer to evacuate at a moment’s notice. The
supply kit is a collection of basic and specific items needed in case of an emergency. The consumer should prepare an HPEN emergency kit as well as a basic emergency kit. Cash, hand sanitizer, flashlight, first aid kit, batteries, battery-powered radio, plastic sheeting, and duct tape are a few of the items that should be included in the basic emergency supply kit. A supply of bottled water that provides 1 gallon of water per person per day is essential. A comprehensive supply list can be found at ready.gov/document/family-supply-list.6,10 The HPEN emergency supply kit should include supplies required to administer the prescribed therapy and maintain catheter access (Tables 6 and 7).9 HPEN consumers should have enough supplies (including enteral formula and home PN solutions) for 5–7 days.9 In addition, the consumer should routinely check the expiration dates of supplies and resupply as necessary. A checklist that lists all items contained in the supply kit, including expiration dates, may be helpful. Specific for HEN consumers, the kit should include extra feeding bags and syringes in case access to safe water is limited. Adequate supply of bottled water is essential for maintaining feeding tube patency and meeting hydration requirements. Feeding pumps for HEN should be kept fully charged. A supply of gravity bags should be part of the emergency supply kit for individuals dependent on infusion pumps who are not candidates for temporary bolus feeding. Written instructions for enteral gravity infusion should be supplied by the homecare provider to be kept in the emergency kit.4 For the home parenteral nutrition (HPN) consumer, not having power available means that HPN solutions cannot be kept cold in the refrigerator and the battery pack for the infusion pump cannot be recharged. Battery packs should be used until the power has drained. Once the battery pack is drained, batteries will be needed to operate the infusion pump. Transferring frozen ice packs from the freezer to the refrigerator may help keep the HPN solution cold in the refrigerator for a longer period. A cooler with ice packs may be necessary to store HPN solutions. HPN consumers should be educated not to infuse solutions that have been at room temperature for more than 48 hours.9
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Table 6. Suggestions for HPN Emergency Supply Kit. •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• ••
Hand sanitizer 70% alcohol solution, paper towels, or sterile Polytowel Extra batteries for infusion pump Power packs for infusion pump Supplies to maintain catheter patency: prepackaged normal saline flush syringe, heparin flush syringe (need for heparin flush will be dependent on catheter type and patient tolerance) Supplies for catheter care: semi-transparent dressing, Micropore tape, sterile gloves, face maska Supplies to administer HPN and maintain sterile technique: pump infusion tubing, alcohol swabs, Swabcaps, positive pressure capb Mercury-free thermometer Foldable IV pole HPN backpack Cooler with frozen ice packs IV hydration bags, appropriate IV administration sets, written instruction for administration Sharps container Bottled water Copy of current HPN prescription Copy of emergency contact list Copy of health information card
HPN, home parenteral nutrition; IV, intravenous. a Comprehensive list of supplies for catheter care will be dependent on physician and homecare provider protocol. b Comprehensive list of supplies to administer HPN will be dependent on physician and homecare provider protocol.
Table 7. Suggestions for HEN Emergency Supply Kit. •• •• •• •• •• •• •• •• •• •• •• •• •• ••
Bottled water Hand sanitizer Hand-operated can opener Extra feeding bags and syringes Supply of gravity tubing with written instruction for administration for HEN consumers dependent on an infusion pump For consumers with low-profile tubes: extra extension sets and replacement tube Foldable IV pole HEN backpack AC adapter for infusion pump Extra batteries if applicable Copy of current HEN prescription Copy of emergency contact list Copy of health information card Contact information for homecare provider RD
HEN, home enteral nutrition; IV, intravenous; RD, registered dietitian.
HPN consumers who have no access to refrigerated HPN solutions or do not have batteries will need to infuse IV hydration. A supply of noncompounded IV hydration with appropriate administration sets should be included in the emergency
kit. Prior education by the homecare nurse should be provided. HPN consumers need to be instructed that IV hydration administration sets cannot be used to administer HPN. A copy of detailed written instructions should be supplied by the homecare provider and kept in the emergency kit.9 Premixed, multichamber PN solutions may be an option for HPN consumers who experience prolonged power and refrigeration outages.8 HPEN consumers should consider purchasing a generator. HPEN consumers need to be prepared for weather-related emergencies and natural disasters. Creating an EPP in advance is an important step to ensure that special needs of the HPEN consumer are met.
Hurricane Sandy: HPN Consumer and Homecare Provider Experience Provider Experience Hurricane Sandy made landfall just north of Atlantic City, New Jersey, at 8 pm on Monday, October 29, 2012. The effects of Sandy, with strong winds, heavy rain, and widespread power outages, had already begun by the afternoon of October 29, 2012. Hurricane warnings are provided 36 hours in advance of anticipated onset of tropical storm force winds; the warning for Hurricane Sandy was issued on Friday, October 26, 2012. A home infusion provider with an infusion branch located in New Jersey was able to activate an EPP on Friday, October 26, 2012. All HPN consumers were notified and inventory of infusion supplies and HPN solutions was assessed by pharmacy support staff. Deliveries, if necessary, were scheduled to occur before the onset of the hurricane was anticipated. Typically, an American global-based courier service was used for scheduled HPN deliveries, but it was anticipated that only local courier service would be available. Weekend homecare nursing visits were scheduled for routine catheter care and laboratory draws prior to the landfall of the storm. Anticipated hospital discharges were either expedited for weekend release or deferred until after the storm. Contingency plans were prepared and backup providers identified. On Monday, October 29, 2012, the New Jersey branch issued an early dismissal for employees and the branch was closed. On October 30, 2014, several branches of the home infusion provider located along the East Coast were unable to open, including the New Jersey branch. Massive flooding, downed trees and electrical transformers, and road and bridge closures made any travel unsafe. The branch in New Jersey was able to reopen on Wednesday, October 31, 2012. HPN consumers were contacted by pharmacy support staff to verify their location and inquire about access to power and refrigeration. Despite the widespread devastation that New Jersey experienced especially along the coastline, none of the HPN consumers required mandatory or forced evacuation. However, many did experience power failure. Some of the consumers relocated temporarily to an alternate address until power could be restored. Some had
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use of a generator. A couple of HPN consumers experience prolonged periods of power failure (for up to 2 weeks). For HPN consumers without power and adequate refrigeration, partial deliveries of HPN solutions were made (3 HPN bags instead of 7). HPN solutions were packed in cooler boxes with extra frozen ice packs prior to leaving the warehouse. Only local courier services were used. Extra batteries were provided as power packs could not be recharged. None of the HPN consumers at this New Jersey branch missed any of their prescribed HPN infusion due to service interruption. Widespread gas station closures presented a challenge to local courier services and homecare nurses. Several homecare nurses reported spending more than 2 hours waiting in line to purchase gas. Some of the nurses opted to travel more than 50 miles to purchase gas rather than wait in line. Nurses’ schedules needed to be adjusted to account for lost time on long gas lines. Limited access to gas also affected HPN consumers who were relying on gas-powered generators for electricity and refrigeration. Downed trees and power lines with closed roads and bridges affected the ability of local couriers to make deliveries and homecare nurses to visit patients. Usual driving routes needed to be altered and required additional time. Deliveries into the city of Hoboken, New Jersey, were not possible for first few days after the storm. Greater than 50% of the roads in Hoboken were flooded. Although it did not affect this branch’s HPN consumers, deliveries of other IV therapies were challenging. Several communities along the Jersey Shore were closed off to prevent looting. In these areas, couriers required police escort to make deliveries to the consumer’s home. Employees of the home infusion provider, specifically the branch located near NYC, were severely affected by the storm. Homes were flooded and cars destroyed. Many employees were displaced for prolonged periods. Following the storm, the coordinated efforts of the New Jersey branch employees, local courier services, and homecare nurses ensured that our HPN consumers received uninterrupted care.
HPN Consumers’ Experience Two long-term HPN consumers shared their personal experience during Hurricane Sandy. The first HPN consumer had been receiving HPN for approximately a year and required daily infusion. This consumer had developed a detailed emergency plan for himself and his family. He had created an emergency kit for both basic and HPN specific items. Previously, he had sent a letter to his utility company outlining his special need for power. He had a backup generator to power a small refrigerator. He had been in contact with the home infusion provider and had adequate supply of HPN solution, IV hydration, and infusion supplies. His homecare nurse visited him on Sunday, October 28, 2012, for routine catheter care and laboratory draw. A blood specimen was dropped off by the homecare nurse at a local laboratory. Results would be directly reported to the
consumer’s physician. Although he did not anticipate any need for evacuation, he does live in close proximity (approximately 3 miles) to beach communities near a major New Jersey bay. He felt he and his family were prepared well enough for the storm and felt confident that his family would remain safe and that he would be able to continue his HPN without any problems. On Monday morning, October 29, 2012, he received a call from his physician. The laboratory results revealed several electrolyte abnormalities. His physician referred him to local hospital for hydration and electrolyte repletion. Anticipating that he might need to stay in the hospital because of the impact of the storm later that day, he packed several days of his HPN solution in a cooler with frozen ice packs along with his supplies and infusion pump. He was admitted to a local hospital that had low risk of flooding. Soon after arriving in the hospital, the hospital lost power and backup generators were used. The local hospital permitted him to infuse his own supply of HPN while admitted. Although stable several hours after receiving IV fluid and electrolyte replacement, he remained hospitalized until Wednesday, October 31, 2012. Closed roads with down trees and power wires as well as flooding prevented him from leaving the hospital. Communication with his family was limited as phone service was out and cell phone service was limited. Fortunately, his family remained safe at home, and he remained safe while hospitalized. He arrived home safely, and HPN solution and supplies were delivered without incident on November 1, 2012. The second HPN consumer has been dependent on HPN since 2008 and requires daily infusion. She had been in contact with the home infusion company prior to the storm and had adequate HPN solution and supplies. This consumer did not have any specific plans for an emergency other than having some basic items on hand such as bottled water and extra batteries. Due to complex medical issues, she also received several injectable medications that required refrigeration. Her home was not located in a flood-prone area, and her community rarely lost power. Like many communities across New Jersey, her household lost power by Monday afternoon. She did have access to safe water, and her home and community did not experience flooding. On Wednesday, she communicated to the home infusion provider that she remained without power. Her husband had tried to purchase a generator, but stores were sold out and could only place their name on a waiting list. She tried to contact her utility company but was advised that they require advanced notice. A home infusion provider assisted her with several partial deliveries of HPN solution packed in a cooler box with extra ice packs until power was restored. A second cooler with additional ice packs was provided for the consumer’s injectable medication. Because of the massive power outages of both households and businesses in her community, availability of ice was limited. This consumer remained without power for nearly 14 days. Fortunately, with the assistance of several neighbors and the home infusion provider, she was able to continue her HPN without interruption.
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HEN Provider and Consumer Experience Many HEN consumers of a home enteral provider were affected. Many of these New Jersey residents experienced displacement from their homes for extended periods, requiring delivery of supplies to an alternate address. Prolonged power outages were common. Although many of these consumers had generators, limited access to gas prevented full use. Some consumers reported running their generator only long enough to fully charge their enteral feeding pump. Several consumers contacted their utility company to request priority for having power resumed; this was successful for a few, but many were advised that paperwork from the consumer’s physician needed to be completed prior to the emergency. Consumers who used infusion pumps required an alternate method of feeding, such as bolus method or gravity feeds. The home enteral provider uses both local and regional distributors to provide enteral formula and supplies. However, due to flooded communities or closed roads and bridges, delivery of enteral product was delayed to some consumers. Several local branches had limited availability of specific formulas. The registered dietitian (RD) played a key role in suggesting an alternate method of feeding and formula substitutions. Creative thinking by the RD as well as thorough knowledge of enteral therapy ensured that consumers’ nutrition needs were met. The following are a few examples. An elderly woman dependent on soy-based formula lived in a disaster-prone area. After the storm, there were no delivery options because of unsafe conditions. No comparable product was available over the counter (OTC). The RD suggested substitution with an infant soy formula and provided mixing instructions to meet her calorie, protein, and micronutrient needs. Several consumers required education on the use of alternate feeding methods. In some cases in which gravity bags could be provided, the RD instructed the consumer or caregiver on drip rate that would be equivalent to pump rate. When gravity bags were not available, the RD provided instructions on how to feed via the bolus method using the syringe consumers had on hand for flushing the feeding tube. The RD needed to assist several consumers on appropriate OTC substitutions for pediatric peptide-based products, making phone calls to help locate product in the consumers’ local area. In addition, the RD provided mixing instructions on how to appropriately dilute or concentrate OTC products to meet the consumers’ needs when delivery from the provider was not possible. The experience of both the HPEN consumers and providers demonstrates the vital importance of advanced planning for weather-related emergencies and natural disasters. Without advanced planning, HPEN consumers would likely experience a disruption in their therapy and significant adverse effects.
Conclusion and Areas of Opportunity HPEN consumers as well as many individuals who receive specialized homecare are at unique risk during weather-related
emergencies and natural disasters. Not only do they need to take measures to protect themselves and their families, but they also need to ensure that their special healthcare needs are met. Homecare providers that service these individuals are responsible for preparing emergency plans that will keep consumers as safe as possible with minimal interruption of service. After experiencing a weather-related emergency such as Hurricane Sandy, areas of opportunity to improve emergency preparedness plans can readily be identified. Improved education for the HPEN consumer by the homecare provider should be a priority. All HPEN consumers should be encouraged to contact their utility company. The homecare provider can assist the consumer in obtaining a physician letter. Based on experience, consumers need to complete this task well in advance of any emergency. Consumers should be educated on completing this task once they begin receiving services from their homecare provider. In addition, HPEN consumers should be encouraged to purchase a generator to allow power for refrigeration and pump recharging. This may not be a financial possibility for all HPEN consumers. In that case, the consumer should seek out nearby family members or neighbors who may be able to assist them. Creation of an EPP manual for the consumer would be very helpful. The manual would cover topics such as (1) emergency contact list, (2) creation of a health information card, and (3) assembling an emergency supply kit, both basic and specific to HPEN. In addition, the manual could provide written instructions for administering IV hydration and, for the HEN consumer, written instructions for administering enteral gravity feeding, including drip rate guidelines. Within the manual, instruction on proper storage of HPEN during an emergency would be useful. An area of opportunity for the HPEN provider is to provide their consumers with supplies to have on hand in case they require an alternate method or type of feeding. For the HPN consumer, having a few days’ supply of noncompounded IV hydration as well administration supplies can potentially prevent an adverse effect from occurring if service to that consumer is interrupted. For the HEN consumer dependent on an infusion pump, having a few days’ supply of gravity bags would be recommended. The Oley Foundation can be a valuable resource of information for the HPEN consumer.8,11 Several resources are available to assist the HPEN consumer in emergency planning.7,12
References 1. U.S. Census Bureau. 2002 Economic Census. Suitland, MD: US Census Bureau; 2002. http://www.census.gov. Accessed February 1, 2014. 2. Lehoux P. Patients’ perspectives on high-tech home care: a qualitative inquiry into the user-friendliness of four technologies. BMC Health Serv Res. 2004:4(1):28. 3. Leff B, Burton JR. The future history of home care and physician house calls in the United States. J Gerontol A Biol Sci Med Sci. 2001;56(10): 603-608.
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4. Emch V, Reddick C. When it rains it pours: disaster preparedness for the home tube feeding patient. 2009. ASPEN Clinical Nutrition Week. http://WeNourish.com/healthcare/clin_research.aspx. Accessed February 1, 2014. 5. Hurricane Sandy. http://en.wikipedia.org/w/index.php?title=Hurricane_ Sandyoldid=590087938. Updated January 10, 2014. Accessed January 10, 2014. 6. Family supply list.FEMA document library,resources and policies website. http://www.ready.gov/document/family-supply-list. Last updated June 27, 2012. Accessed January 10, 2014. 7. Zane R, Biddinger P. Home Health Patient Assessment Tools: Preparing for Emergency Triage. Rockville, MD: Agency for Healthcare Research and Quality; March 2011. AHRQ Publication No. 11-M020-EF.
8. The Oley Foundation. Tools for living better on home IV & tube feedings. http://oley.org/lifeline/Nutrition_and_You_Be_Prepared.html. Published LifeLine Letter September/October 2011. Accessed January 10, 2012. 9. BC HCN Program. My emergency preparedness plan information for and about adult patients of the BC Home Parenteral Nutrition (HPN) Program. April 2013. http://www.bchomenutrition.org. Accessed January 10, 2014. 10. Hamilton K. When disaster strikes: how you can be prepared. Celebrate Life. 2013;30:13-15. 11. The Oley Foundation. Packet for travel and hospital admissions. http:// www.oley.org/travelpack.html. Accessed January 10, 2014. 12. Special populations: emergency and disaster preparedness. http://sis.nlm. nih.gov/outreach/specialpopulationsanddisasters.html. Accessed January 10, 2014.
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research-article2014
NCPXXX10.1177/0884533614536927Nutrition in Clinical PracticeTrento and Allen
Invited Review
Hurricane Sandy: Nutrition Support During Disasters Laura Trento, MS, RD, CNSC1; and Sarah Allen, MS, RD, LDN2
Nutrition in Clinical Practice Volume 29 Number 5 October 2014 576–584 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614536927 ncp.sagepub.com hosted at online.sagepub.com
Abstract Natural disasters and weather-related emergencies can strike at a moment’s notice. Individuals with chronic health conditions and other special needs are especially vulnerable. Basic services such as water, electricity, gas, and telephone service may not be available. Home parenteral and enteral nutrition consumers are at a serious risk as they depend on clean water and power for nutrient delivery. Creating a comprehensive emergency preparedness plan is imperative for both the home parenteral and enteral consumer and home care provider to ensure that special needs are met. Home care providers can assist home parenteral and enteral consumers in disaster and emergency planning. (Nutr Clin Pract. 2014;29:576-584)
Keywords nutritional support; home parenteral nutrition; disasters; emergencies; risk management; home care services; enteral nutrition; parenteral nutrition
Natural disasters and weather-related emergencies can strike quickly and without advanced warning, including earthquakes, tornadoes, avalanches, landslides, floods, and forest fires. Others, such as hurricanes and snowstorms, provide some degree of advanced warning. These disasters can have a devastating effect on individuals and the community at large. Basic services such as water, electricity, gasoline, and telephone service may not be available. Mandatory and forced evacuation may be necessary or confinement to the home. Individuals with chronic health conditions and other special needs are especially vulnerable. Disasters and weather-related emergencies present a serious challenge to these individuals. Approximately 7 million individuals in the United States receive homecare from 17,000 homecare providers because of acute illness, chronic conditions, permanent disability, or terminal illness.1 Technological advancement has permitted many chronic health conditions to be managed in the home. Ventilators, oxygen therapy, peritoneal dialysis, feeding pumps, intravenous (IV) fluids, and parenteral nutrition (PN) are few examples of advancements that have contributed to the expansion of homecare.2,3 Individuals dependent on home parenteral and enteral nutrition (HPEN) are at increased risk because of their dependence on electricity and clean water. In addition, they depend on homecare providers for delivery of enteral formula, home parenteral solutions, and administration supplies. This dependence makes being prepared for a disaster a shared responsibility. Homecare providers should have an emergency preparedness plan (EPP) in place for each type of disaster. The plan needs to be reviewed frequently in order for the homecare provider to meet the needs of the HPEN consumer.4 The HPEN consumer should take an active role in planning for emergencies to ensure the plan meets the consumer’s specific needs. Involving the consumer in the
planning process may also help him or her feel more confident should disaster strike. We present clinical and operational experience during one such weather-related emergency: Hurricane Sandy. Challenges in the provision of nutrition support services to the HPEN consumer during the aftermath of the storm are presented. A review of emergency preparedness plans for the homecare provider and HPEN consumer is discussed.
The Impact of Hurricane Sandy Hurricane Sandy (officially referred as post–tropical cyclone Sandy) was the most destructive hurricane of the 2012 Atlantic hurricane season.5 Unofficially known as Superstorm Sandy or Frankenstorm, it began as a tropical storm in the Caribbean on October 22, 2012. It made landfall as a hurricane in Jamaica on October 24, 2012. Temporarily weakened to a tropical storm after passing over the Bahamas on October 27, 2012, it regained strength as a category 1 hurricane before turning toward the eastern U.S. coast (Table 1).5,6 Landfall in the United States occurred at 8 pm on October 29, 2012, just north of Atlantic City, New Jersey. Although it was a category 2 storm as it approached the coast of the northeastern United States, the storm became the largest Atlantic hurricane on record with the winds spanning out a diameter of From 1Coram Specialty Infusion Services, Totowa, New Jersey, and 2 Coram Specialty Infusion Services, Jackson, Tennessee. Financial disclosure: None declared. This article originally appeared online on June 25, 2014. Corresponding Author: Laura Trento, MS, RD, CNSC, Coram Specialty Infusion Services, 11 Commerce Way, Totowa, NJ 07512, USA. Email: [email protected]
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Table 1. Saffir-Simpson Hurricane Scale. Scale Number (Category)
Sustained Winds, mph
1
74–95
2
96–110
3
111–129
4
130–156
5
157 or higher
Damage
Storm Surge, ft
Minor damage to exterior of homes Toppled trees Damaged power lines, power outages Extensive damage will occur Major damage to exterior of homes Uprooting small trees, blocked roads Power outages for days to weeks Devastating damage will occur Extensive damage to exterior of homes Many trees uprooted, many blocked roads Limited availability of water and power Catastrophic damage will occur Loss of roof and/or exterior walls Most trees uprooted and most power lines down Residential roads cut off Power outages for weeks to months Catastrophic damage will occur High percentage of homes destroyed Major roads cut off by fallen trees and power lines
4–5
Figure 1. Satellite image of Hurricane Sandy near landfall on October 29, 2012. Source: U.S. National Oceanic and Atmospheric Administration.
1100 miles (Figure 1).5 The impact of the storm was felt across more than a dozen states. The entire East Coast from Florida to Maine was affected. The densely populated states of New York and New Jersey were severely affected with heavy rain, strong winds, and record storm surges (Table 2).5,6 New York City (NYC), surrounding suburban communities, and Long Island were severely affected. Life-threatening
6–8
9–12
13–18
18 or more
flooding occurred in the NYC subway system; all road tunnels entering Manhattan, New York (with the exception of the Lincoln Tunnel); and many coastline communities. Numerous homes and businesses were destroyed by fire, including more than 100 homes in Breezy Point, Queens, New York.5 Many parts of NYC were without power for several days. Numerous NYC hospitals and nursing homes required closure or sudden evacuation. In preparation for the storm, mandatory evacuations of coastal communities of Long Island, lower Manhattan, Staten Island, Brooklyn, and Queens were implemented. All subway, bus, and commuter rail service was suspended by the evening of October 28, 2012. All bridges, tunnels, and ferry service were shut down as of the afternoon of October 29, 2012. All flights in and out of the major New York and New Jersey airports were cancelled.5 The effects of Hurricane Sandy on New Jersey were devastating. The New Jersey shoreline suffered the most severe winds (as high as 90 mph) and surf. Mantoloking, New Jersey, a small oceanfront community, suffered severe “wash over,” with the creation of 2 temporary inlets (Figure 2).5 More than 2 dozen homes were completely removed from their foundation. Many homes and businesses in the seaside communities were destroyed by storm surge, leaving up to 4 feet of sand in streets, rendering them impassable.5 Historic boardwalks, amusement parks, and marinas along the New Jersey shoreline were destroyed (Figure 3).5 Communities along the west Hudson waterfront (across the Hudson River from NYC) were flooded by storm surge. Half the city of Hoboken, New Jersey was flooded. Numerous fire stations in both New York and New Jersey required evacuation. Communities in other areas of New Jersey required forced
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Table 2. Hurricanes and Important Definitions. Weather-Related Emergency Tropical storm Hurricane Tropical storm warning Tropical storm watch Hurricane warning Hurricane watch Storm surge
Definition A tropical cyclone with maximum sustained surface wind speed of 39–73 mph. A tropical cyclone with maximum sustained surface wind speed of 74 mph or more. An announcement that tropical storm conditions are expected somewhere within a specified area within 36 hours. An announcement that tropical storm conditions are possible within a specified area within 48 hours. An announcement that hurricane conditions are expected within a specified area. Hurricane warnings are issued 36 hours in advance of the anticipated onset of tropical storm force winds. An announcement that hurricane conditions are possible within a specified area. Hurricane watch is issued 48 hours in advance of the anticipated onset of tropical storm force winds. An abnormal rise in sea level accompanying a hurricane or other intense storm and whose height is the difference between the observed level of the sea surface and the level that would have occurred in the absence of the cyclone. Storm surge is estimated by subtracting the normal or astronomic high tide from the observed storm tide. A storm surge can reach heights of well over 20 feet and can span hundreds of miles of coastline.
Figure 2. Aerial view during army search and rescue mission in Mantoloking, New Jersey, on October 30, 2012. Source: U.S. Air Force.
evacuation and rescue after a berm and river overflowed due to storm surge. There were reports of up to 5 feet of water in the streets of Little Ferry and Moonachie, New Jersey.5 On the morning of October 30, 2012, more than 2 million households and businesses in New Jersey were without power. As of November 9, 2012, a total of 265,000 homes and businesses remained without power. More than 346,000 homes were destroyed or damaged, with 22,000 homes completely inhabitable.5 Most gas stations in NYC and New Jersey were closed because of power shortages and depleted fuel supplies. Sixty percent of the gas stations in New Jersey remained closed as of November 2, 2012. Odd-even rationing (based on license plate numbers) of gas purchases was implemented by the governor of New Jersey to help prevent fuel shortages and reduce long waiting times.5 In total, some 4.7 million households in 15 states were without power. Some remained without power for up to 2 weeks after the storm. Drinking water in several New Jersey and New York communities was deemed unsafe. Transportation systems in both New Jersey and New York were severely affected. Restoration of full rail service from Hoboken into Manhattan took until January 2013 to complete. As of April 2013, a total of 39,000 families in New Jersey were still unable to return to their homes.5 Hurricane Sandy remains one of the most costly natural disasters in the United States. In NYC alone, the economic loss was $19 billion; in New Jersey, the cost was estimated at $30 billion (Table 3).5
Planning and Preparing for Emergencies for the Professional Figure 3. Aerial view of damage to Casino Pier in Seaside Heights, New Jersey. Source: New Jersey National Guard.
During the aftermath of a natural disaster or weather-related emergency, access to electricity and safe water may be limited or not available. Telephone services may be out and roads and
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Table 3. Costliest U.S. Atlantic Hurricanes. Rank
Hurricane
1 2 3 4 5 6 7 8 9 10
Katrina Sandy Ike Andrew Wilma Ivan Irene Charley Rita Frances
Season
Damage
2005 2012 2008 1992 2005 2004 2011 2004 2005 2004
$108 billion $65 billion $29.5 billion $26.5 billion $21 billion $18.8 billion $15.6 billion $15.1 billion $12 billion $9.51 billion
Cost refers to total estimated property damage.
bridges impassable. Hospitals and emergency rooms may be overcrowded or completely closed. HPEN consumers could experience disruption of needed support services. Disruption of services may lead to serious adverse effects. As HPEN consumers rely on power and safe water to administer prescribed therapy, planning in advance of an emergency is imperative. Emergency preparedness planning is a shared responsibility. Homecare providers need to provide their expertise to help guide and support HPEN consumers.4 The objective of an EPP for the homecare provider is to (1) ensure safety of consumers and employees, (2) minimize any interruption of services, and (3) prepare contingency plans or designate a back-up provider. The priority during an emergency situation is the safety of human life while preserving property, equipment, and records. An organization’s EPP plan should incorporate a patient risk assessment tool. The goal of the tool would allow the homecare provider to identify individuals at risk for hospital admission if homecare services were to be interrupted. The tool would help homecare providers anticipate the needs of their patients.7 Storm-related emergencies and disasters with advanced warning would allow sufficient time to review patient lists and prioritize care. Standardization of risk levels has been recommended for homecare providers (Table 4).7 Categories for assessing risk could include level of care needs, clinical diagnosis, caregiver support, and timeframes for visits.7 In the case of the home infusion provider, therapy type may be used in assessing risk level. Designing systems that can print or transmit lists of high-risk patients to emergency responders is suggested.7 Advanced warning of a weather-related emergency or disaster will allow homecare providers to contact HPEN consumers prior to the event. Contact should include an inventory of supplies in the home (including enteral formula and home PN solutions), which will identify any urgent need for delivery of supplies. Consumer need for a homecare nursing visit can also be assessed. The homecare provider should inquire if the HPEN consumer requires or may require mandatory evacuation. Alternate address and telephone number should be obtained in
case of evacuation or anticipation of loss of telephone service; an alternate number for contact (designated back-up provider or message center) should also be provided to the HPEN consumer. For the homecare provider that services home enteral nutrition (HEN) consumers, inventory of equipment and supplies available locally and what may be readily obtained from regional or national warehouses should be conducted.4 HEN consumers who require use of a feeding pump for infusion of the enteral product will need to be identified. In the advent of a power failure, an alternate method of feeding may be necessary; education on an alternate feeding method will be required.4 Consumers should be contacted by their homecare provider within the first 12–48 hours of the emergency condition with priority of contact based on the patient risk assessment. Consumers should be assessed for the following: (1) safety and security of current location, (2) days of supplies (including enteral formula and home PN solutions) remaining in the home, (3) access to electricity and safe water, and (4) need for homecare nursing visit. If a consumer requires evacuation, verification of the evacuation destination will be required. For HEN consumers who require a feeding pump and are without power, the provider needs to assess gravity bag availability and need for education by a registered dietitian.7
Planning and Preparing for Emergencies for the Consumer “Be prepared” is one of the best mottos for an HPEN consumer.8 Planning in advance of an emergency will ensure that the consumer’s unique needs are met and therapy can continued uninterrupted. HPEN consumers’ EPP involves knowing the risks, making a plan, and having an emergency supply kit.9 Consumers will need to determine if they can remain safely at home or will require evacuation. Evacuation may be advised or mandatory. The amount of time required to leave will depend on the impending emergency. Usually, 1–2 days of advanced notice is provided prior to a storm. In some circumstances, sudden evacuation or rescue is required. In that case, there will be limited time to gather even bare necessities. Evacuation may be by car, ambulance, military vehicle, or air transport. Temporary shelter may involve staying with friends or relatives, commercial lodging, or a mass care facility operated by disaster relief groups.6 HPEN consumers should consider wearing a medical alert bracelet that is registered with a medical alert company or carry a USB flash drive that will allow medical personnel easy access to medical information.9 An emergency contact list should be prepared and include names and contact information for designated family and friends, physicians, and pharmacy and homecare providers (infusion provider, durable medical equipment provider, and nursing provider).10 Consumers should consider entering the emergency contact list into their personal cell phone contacts as ICE (in case of emergency).9 A
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Table 4. Assessment for Patient Risk. Risk Level
Needs Assessment
High risk or high priority
Requires uninterrupted services Requires life-sustaining equipment Needs regularly scheduled RN visit
Medium risk or medium priority
No immediate threat to life May suffer adverse effect if homecare service interrupted
Low risk or low priority
Would not suffer major adverse effect if homecare services interrupted
Therapy Type Inotropes Ventilator dependent Oxygen dependent Lack of caregiver Complex wound care HPEN Pain management IV hydration IV antibiotics Caregiver available
HPEN, home parenteral and enteral nutrition: IV, intravenous; RN, registered nurse.
Table 5. Health Information Card. •• •• •• •• •• •• •• •• •• •• ••
Address and phone number Emergency contact list Physician name and phone number Pharmacy name and phone number Homecare provider name and phone number (infusion, DME, nursing) Blood type Allergies Special equipment needs Medication list (list dose, frequency, and reason for use) Disabilities and other medical conditions Copy of current HPEN prescription
DME, durable medical equipment; HPEN, home parenteral and enteral nutrition.
copy of the emergency contact list should be kept in the consumer’s emergency supply kit. HPEN consumers can contact their utility company as part of their EPP. Many utility companies keep a list and map of locations of power-dependent customers.6 A letter from the HPEN consumer that contains (1) name and address of the person with specific medical needs, (2) physician’s registration number (National Provider Identifier number), (3) signature of the physician, and (4) explanation of the medical need for power to run the pump and refrigeration to maintain temperature of home PN solutions will need to be on record with the utility company prior to the event.10 A health information card should be created (Table 5).9,10 The Packet for Travel and Hospital Admissions, available through the Oley Foundation, can be used as a template. The packet is meant to help consumers communicate medical needs and history to hospital personnel. It can be quite useful during emergency situations.11 Consumers should keep a copy of their health information card or Packet for Travel and Hospital Admissions in the emergency supply kit. Assembling an emergency supply kit in advance will allow the HPEN consumer to evacuate at a moment’s notice. The
supply kit is a collection of basic and specific items needed in case of an emergency. The consumer should prepare an HPEN emergency kit as well as a basic emergency kit. Cash, hand sanitizer, flashlight, first aid kit, batteries, battery-powered radio, plastic sheeting, and duct tape are a few of the items that should be included in the basic emergency supply kit. A supply of bottled water that provides 1 gallon of water per person per day is essential. A comprehensive supply list can be found at ready.gov/document/family-supply-list.6,10 The HPEN emergency supply kit should include supplies required to administer the prescribed therapy and maintain catheter access (Tables 6 and 7).9 HPEN consumers should have enough supplies (including enteral formula and home PN solutions) for 5–7 days.9 In addition, the consumer should routinely check the expiration dates of supplies and resupply as necessary. A checklist that lists all items contained in the supply kit, including expiration dates, may be helpful. Specific for HEN consumers, the kit should include extra feeding bags and syringes in case access to safe water is limited. Adequate supply of bottled water is essential for maintaining feeding tube patency and meeting hydration requirements. Feeding pumps for HEN should be kept fully charged. A supply of gravity bags should be part of the emergency supply kit for individuals dependent on infusion pumps who are not candidates for temporary bolus feeding. Written instructions for enteral gravity infusion should be supplied by the homecare provider to be kept in the emergency kit.4 For the home parenteral nutrition (HPN) consumer, not having power available means that HPN solutions cannot be kept cold in the refrigerator and the battery pack for the infusion pump cannot be recharged. Battery packs should be used until the power has drained. Once the battery pack is drained, batteries will be needed to operate the infusion pump. Transferring frozen ice packs from the freezer to the refrigerator may help keep the HPN solution cold in the refrigerator for a longer period. A cooler with ice packs may be necessary to store HPN solutions. HPN consumers should be educated not to infuse solutions that have been at room temperature for more than 48 hours.9
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Table 6. Suggestions for HPN Emergency Supply Kit. •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• ••
Hand sanitizer 70% alcohol solution, paper towels, or sterile Polytowel Extra batteries for infusion pump Power packs for infusion pump Supplies to maintain catheter patency: prepackaged normal saline flush syringe, heparin flush syringe (need for heparin flush will be dependent on catheter type and patient tolerance) Supplies for catheter care: semi-transparent dressing, Micropore tape, sterile gloves, face maska Supplies to administer HPN and maintain sterile technique: pump infusion tubing, alcohol swabs, Swabcaps, positive pressure capb Mercury-free thermometer Foldable IV pole HPN backpack Cooler with frozen ice packs IV hydration bags, appropriate IV administration sets, written instruction for administration Sharps container Bottled water Copy of current HPN prescription Copy of emergency contact list Copy of health information card
HPN, home parenteral nutrition; IV, intravenous. a Comprehensive list of supplies for catheter care will be dependent on physician and homecare provider protocol. b Comprehensive list of supplies to administer HPN will be dependent on physician and homecare provider protocol.
Table 7. Suggestions for HEN Emergency Supply Kit. •• •• •• •• •• •• •• •• •• •• •• •• •• ••
Bottled water Hand sanitizer Hand-operated can opener Extra feeding bags and syringes Supply of gravity tubing with written instruction for administration for HEN consumers dependent on an infusion pump For consumers with low-profile tubes: extra extension sets and replacement tube Foldable IV pole HEN backpack AC adapter for infusion pump Extra batteries if applicable Copy of current HEN prescription Copy of emergency contact list Copy of health information card Contact information for homecare provider RD
HEN, home enteral nutrition; IV, intravenous; RD, registered dietitian.
HPN consumers who have no access to refrigerated HPN solutions or do not have batteries will need to infuse IV hydration. A supply of noncompounded IV hydration with appropriate administration sets should be included in the emergency
kit. Prior education by the homecare nurse should be provided. HPN consumers need to be instructed that IV hydration administration sets cannot be used to administer HPN. A copy of detailed written instructions should be supplied by the homecare provider and kept in the emergency kit.9 Premixed, multichamber PN solutions may be an option for HPN consumers who experience prolonged power and refrigeration outages.8 HPEN consumers should consider purchasing a generator. HPEN consumers need to be prepared for weather-related emergencies and natural disasters. Creating an EPP in advance is an important step to ensure that special needs of the HPEN consumer are met.
Hurricane Sandy: HPN Consumer and Homecare Provider Experience Provider Experience Hurricane Sandy made landfall just north of Atlantic City, New Jersey, at 8 pm on Monday, October 29, 2012. The effects of Sandy, with strong winds, heavy rain, and widespread power outages, had already begun by the afternoon of October 29, 2012. Hurricane warnings are provided 36 hours in advance of anticipated onset of tropical storm force winds; the warning for Hurricane Sandy was issued on Friday, October 26, 2012. A home infusion provider with an infusion branch located in New Jersey was able to activate an EPP on Friday, October 26, 2012. All HPN consumers were notified and inventory of infusion supplies and HPN solutions was assessed by pharmacy support staff. Deliveries, if necessary, were scheduled to occur before the onset of the hurricane was anticipated. Typically, an American global-based courier service was used for scheduled HPN deliveries, but it was anticipated that only local courier service would be available. Weekend homecare nursing visits were scheduled for routine catheter care and laboratory draws prior to the landfall of the storm. Anticipated hospital discharges were either expedited for weekend release or deferred until after the storm. Contingency plans were prepared and backup providers identified. On Monday, October 29, 2012, the New Jersey branch issued an early dismissal for employees and the branch was closed. On October 30, 2014, several branches of the home infusion provider located along the East Coast were unable to open, including the New Jersey branch. Massive flooding, downed trees and electrical transformers, and road and bridge closures made any travel unsafe. The branch in New Jersey was able to reopen on Wednesday, October 31, 2012. HPN consumers were contacted by pharmacy support staff to verify their location and inquire about access to power and refrigeration. Despite the widespread devastation that New Jersey experienced especially along the coastline, none of the HPN consumers required mandatory or forced evacuation. However, many did experience power failure. Some of the consumers relocated temporarily to an alternate address until power could be restored. Some had
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use of a generator. A couple of HPN consumers experience prolonged periods of power failure (for up to 2 weeks). For HPN consumers without power and adequate refrigeration, partial deliveries of HPN solutions were made (3 HPN bags instead of 7). HPN solutions were packed in cooler boxes with extra frozen ice packs prior to leaving the warehouse. Only local courier services were used. Extra batteries were provided as power packs could not be recharged. None of the HPN consumers at this New Jersey branch missed any of their prescribed HPN infusion due to service interruption. Widespread gas station closures presented a challenge to local courier services and homecare nurses. Several homecare nurses reported spending more than 2 hours waiting in line to purchase gas. Some of the nurses opted to travel more than 50 miles to purchase gas rather than wait in line. Nurses’ schedules needed to be adjusted to account for lost time on long gas lines. Limited access to gas also affected HPN consumers who were relying on gas-powered generators for electricity and refrigeration. Downed trees and power lines with closed roads and bridges affected the ability of local couriers to make deliveries and homecare nurses to visit patients. Usual driving routes needed to be altered and required additional time. Deliveries into the city of Hoboken, New Jersey, were not possible for first few days after the storm. Greater than 50% of the roads in Hoboken were flooded. Although it did not affect this branch’s HPN consumers, deliveries of other IV therapies were challenging. Several communities along the Jersey Shore were closed off to prevent looting. In these areas, couriers required police escort to make deliveries to the consumer’s home. Employees of the home infusion provider, specifically the branch located near NYC, were severely affected by the storm. Homes were flooded and cars destroyed. Many employees were displaced for prolonged periods. Following the storm, the coordinated efforts of the New Jersey branch employees, local courier services, and homecare nurses ensured that our HPN consumers received uninterrupted care.
HPN Consumers’ Experience Two long-term HPN consumers shared their personal experience during Hurricane Sandy. The first HPN consumer had been receiving HPN for approximately a year and required daily infusion. This consumer had developed a detailed emergency plan for himself and his family. He had created an emergency kit for both basic and HPN specific items. Previously, he had sent a letter to his utility company outlining his special need for power. He had a backup generator to power a small refrigerator. He had been in contact with the home infusion provider and had adequate supply of HPN solution, IV hydration, and infusion supplies. His homecare nurse visited him on Sunday, October 28, 2012, for routine catheter care and laboratory draw. A blood specimen was dropped off by the homecare nurse at a local laboratory. Results would be directly reported to the
consumer’s physician. Although he did not anticipate any need for evacuation, he does live in close proximity (approximately 3 miles) to beach communities near a major New Jersey bay. He felt he and his family were prepared well enough for the storm and felt confident that his family would remain safe and that he would be able to continue his HPN without any problems. On Monday morning, October 29, 2012, he received a call from his physician. The laboratory results revealed several electrolyte abnormalities. His physician referred him to local hospital for hydration and electrolyte repletion. Anticipating that he might need to stay in the hospital because of the impact of the storm later that day, he packed several days of his HPN solution in a cooler with frozen ice packs along with his supplies and infusion pump. He was admitted to a local hospital that had low risk of flooding. Soon after arriving in the hospital, the hospital lost power and backup generators were used. The local hospital permitted him to infuse his own supply of HPN while admitted. Although stable several hours after receiving IV fluid and electrolyte replacement, he remained hospitalized until Wednesday, October 31, 2012. Closed roads with down trees and power wires as well as flooding prevented him from leaving the hospital. Communication with his family was limited as phone service was out and cell phone service was limited. Fortunately, his family remained safe at home, and he remained safe while hospitalized. He arrived home safely, and HPN solution and supplies were delivered without incident on November 1, 2012. The second HPN consumer has been dependent on HPN since 2008 and requires daily infusion. She had been in contact with the home infusion company prior to the storm and had adequate HPN solution and supplies. This consumer did not have any specific plans for an emergency other than having some basic items on hand such as bottled water and extra batteries. Due to complex medical issues, she also received several injectable medications that required refrigeration. Her home was not located in a flood-prone area, and her community rarely lost power. Like many communities across New Jersey, her household lost power by Monday afternoon. She did have access to safe water, and her home and community did not experience flooding. On Wednesday, she communicated to the home infusion provider that she remained without power. Her husband had tried to purchase a generator, but stores were sold out and could only place their name on a waiting list. She tried to contact her utility company but was advised that they require advanced notice. A home infusion provider assisted her with several partial deliveries of HPN solution packed in a cooler box with extra ice packs until power was restored. A second cooler with additional ice packs was provided for the consumer’s injectable medication. Because of the massive power outages of both households and businesses in her community, availability of ice was limited. This consumer remained without power for nearly 14 days. Fortunately, with the assistance of several neighbors and the home infusion provider, she was able to continue her HPN without interruption.
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HEN Provider and Consumer Experience Many HEN consumers of a home enteral provider were affected. Many of these New Jersey residents experienced displacement from their homes for extended periods, requiring delivery of supplies to an alternate address. Prolonged power outages were common. Although many of these consumers had generators, limited access to gas prevented full use. Some consumers reported running their generator only long enough to fully charge their enteral feeding pump. Several consumers contacted their utility company to request priority for having power resumed; this was successful for a few, but many were advised that paperwork from the consumer’s physician needed to be completed prior to the emergency. Consumers who used infusion pumps required an alternate method of feeding, such as bolus method or gravity feeds. The home enteral provider uses both local and regional distributors to provide enteral formula and supplies. However, due to flooded communities or closed roads and bridges, delivery of enteral product was delayed to some consumers. Several local branches had limited availability of specific formulas. The registered dietitian (RD) played a key role in suggesting an alternate method of feeding and formula substitutions. Creative thinking by the RD as well as thorough knowledge of enteral therapy ensured that consumers’ nutrition needs were met. The following are a few examples. An elderly woman dependent on soy-based formula lived in a disaster-prone area. After the storm, there were no delivery options because of unsafe conditions. No comparable product was available over the counter (OTC). The RD suggested substitution with an infant soy formula and provided mixing instructions to meet her calorie, protein, and micronutrient needs. Several consumers required education on the use of alternate feeding methods. In some cases in which gravity bags could be provided, the RD instructed the consumer or caregiver on drip rate that would be equivalent to pump rate. When gravity bags were not available, the RD provided instructions on how to feed via the bolus method using the syringe consumers had on hand for flushing the feeding tube. The RD needed to assist several consumers on appropriate OTC substitutions for pediatric peptide-based products, making phone calls to help locate product in the consumers’ local area. In addition, the RD provided mixing instructions on how to appropriately dilute or concentrate OTC products to meet the consumers’ needs when delivery from the provider was not possible. The experience of both the HPEN consumers and providers demonstrates the vital importance of advanced planning for weather-related emergencies and natural disasters. Without advanced planning, HPEN consumers would likely experience a disruption in their therapy and significant adverse effects.
Conclusion and Areas of Opportunity HPEN consumers as well as many individuals who receive specialized homecare are at unique risk during weather-related
emergencies and natural disasters. Not only do they need to take measures to protect themselves and their families, but they also need to ensure that their special healthcare needs are met. Homecare providers that service these individuals are responsible for preparing emergency plans that will keep consumers as safe as possible with minimal interruption of service. After experiencing a weather-related emergency such as Hurricane Sandy, areas of opportunity to improve emergency preparedness plans can readily be identified. Improved education for the HPEN consumer by the homecare provider should be a priority. All HPEN consumers should be encouraged to contact their utility company. The homecare provider can assist the consumer in obtaining a physician letter. Based on experience, consumers need to complete this task well in advance of any emergency. Consumers should be educated on completing this task once they begin receiving services from their homecare provider. In addition, HPEN consumers should be encouraged to purchase a generator to allow power for refrigeration and pump recharging. This may not be a financial possibility for all HPEN consumers. In that case, the consumer should seek out nearby family members or neighbors who may be able to assist them. Creation of an EPP manual for the consumer would be very helpful. The manual would cover topics such as (1) emergency contact list, (2) creation of a health information card, and (3) assembling an emergency supply kit, both basic and specific to HPEN. In addition, the manual could provide written instructions for administering IV hydration and, for the HEN consumer, written instructions for administering enteral gravity feeding, including drip rate guidelines. Within the manual, instruction on proper storage of HPEN during an emergency would be useful. An area of opportunity for the HPEN provider is to provide their consumers with supplies to have on hand in case they require an alternate method or type of feeding. For the HPN consumer, having a few days’ supply of noncompounded IV hydration as well administration supplies can potentially prevent an adverse effect from occurring if service to that consumer is interrupted. For the HEN consumer dependent on an infusion pump, having a few days’ supply of gravity bags would be recommended. The Oley Foundation can be a valuable resource of information for the HPEN consumer.8,11 Several resources are available to assist the HPEN consumer in emergency planning.7,12
References 1. U.S. Census Bureau. 2002 Economic Census. Suitland, MD: US Census Bureau; 2002. http://www.census.gov. Accessed February 1, 2014. 2. Lehoux P. Patients’ perspectives on high-tech home care: a qualitative inquiry into the user-friendliness of four technologies. BMC Health Serv Res. 2004:4(1):28. 3. Leff B, Burton JR. The future history of home care and physician house calls in the United States. J Gerontol A Biol Sci Med Sci. 2001;56(10): 603-608.
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4. Emch V, Reddick C. When it rains it pours: disaster preparedness for the home tube feeding patient. 2009. ASPEN Clinical Nutrition Week. http://WeNourish.com/healthcare/clin_research.aspx. Accessed February 1, 2014. 5. Hurricane Sandy. http://en.wikipedia.org/w/index.php?title=Hurricane_ Sandyoldid=590087938. Updated January 10, 2014. Accessed January 10, 2014. 6. Family supply list.FEMA document library,resources and policies website. http://www.ready.gov/document/family-supply-list. Last updated June 27, 2012. Accessed January 10, 2014. 7. Zane R, Biddinger P. Home Health Patient Assessment Tools: Preparing for Emergency Triage. Rockville, MD: Agency for Healthcare Research and Quality; March 2011. AHRQ Publication No. 11-M020-EF.
8. The Oley Foundation. Tools for living better on home IV & tube feedings. http://oley.org/lifeline/Nutrition_and_You_Be_Prepared.html. Published LifeLine Letter September/October 2011. Accessed January 10, 2012. 9. BC HCN Program. My emergency preparedness plan information for and about adult patients of the BC Home Parenteral Nutrition (HPN) Program. April 2013. http://www.bchomenutrition.org. Accessed January 10, 2014. 10. Hamilton K. When disaster strikes: how you can be prepared. Celebrate Life. 2013;30:13-15. 11. The Oley Foundation. Packet for travel and hospital admissions. http:// www.oley.org/travelpack.html. Accessed January 10, 2014. 12. Special populations: emergency and disaster preparedness. http://sis.nlm. nih.gov/outreach/specialpopulationsanddisasters.html. Accessed January 10, 2014.
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