DEEP
Center
Copyright © 2004: All Rights Reserved

Disaster Behavioral Health Awareness
Training for Health Care Professionals
James M. Shultz MS, PhD
Zelde Espinel MD, MA, MPH
Raquel E. Cohen MD, MPH
Jorge R. Insignares MD
Lisa Rosenfeld MPH
DEEP Center
University of Miami
School of Medicine
Brian W. Flynn EdD
Rear Admiral, USPHS (Ret)
Assistant Surgeon
General (Ret)
Jon A. Shaw MD, MS
Department of Psychiatry
University of Miami
School of Medicine
Robert J. Ursano MD
Director, Center for the Study of
Traumatic Stress
Uniformed Services University of the Health Sciences
Joseph A. Barbera MD
Director
Institute for Crisis, Disaster, and
Risk Management
The George Washington University
Mauricio Lynn MD
Abdul Memon MD
S. Shai Gold
Jackson Memorial Medical Center
University of Miami
School of Medicine

DISASTER BEHAVIORAL HEALTH AWARENESS TRAINING FOR HEALTH CARE PROFESSIONALS
HOSPITAL AS A PATIENT CARE PROVIDER:

Patient Care
Strategies
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
Plan
Prepare & Mitigate
Pre-event
Train Drill
Respond
Event
Recover
Post-event
Evaluate Activate Restore Evaluate

Patient Care Strategies II
Key Concepts

Manage contamination, isolation, and quarantine

Maintain ongoing quality patient care

Patient Care
Strategies
Expand surge capacity
Conduct behavioral triage
Conduct behavioral intervention
Manage contamination, isolation, quarantine
Maintain quality patient care
Support patient families
Meet special population needs
Provide culturally-competent care
Communicate with the public
Plan
Prepare & Mitigate
Pre-event
Train Drill
Respond
Event
Recover
Post-event
Evaluate Activate Restore Evaluate

Goal: Manage
Special Contingencies

Plan for Special Contingencies

Potentially-exposed patients

Patients selected for:

Decontamination

Isolation

Manage Special Contingencies —
Potentially-exposed Patients

Potentially-exposed Patients

Provide full registration for all victims.

Provide written information after decontamination, triage, and initial treatment, including agent-specific information.

Provide information as it becomes available:

Patient care information

Test results

Credible event information

Emphasize the positive actions being taken.
Source: Barbera & McIntyre,2003, Jane’s Mass Casualty Handbook: Hospital

Potentially-exposed Patients

Monitor patients under observation for delayed symptoms.

Enroll discharged patients in a surveillance system.

Provide behavioral health evaluation and referral if indicated.

Provide written information on normal reactions to stress and community resources.
Source: Barbera & McIntyre,2003, Jane’s Mass Casualty Handbook: Hospital

Manage Special Contingencies —
Patients Needing Decontamination

Behavioral Goal:

Decrease hyperarousal

Decrease anxiety and fear
Strategies:

Explain procedure

Remove activities from public view

Permanent Decon Area
Jackson Memorial Medical Center, Miami, FL

Post-Decontamination Triage Area
Jackson Memorial Medical Center, Miami, FL

Manage Special Contingencies —
Patients Needing Isolation
“Virtual visit” to the hospital during the SARS outbreak,
Hong Kong, 2003

Public Health
Disease Containment
Quarantine:
Compulsory physical separation, including restriction of movement, of populations or groups of healthy people who have been potentially exposed to a contagious disease , or efforts to segregate these persons within specified geographic areas.
Source: Barbera et al., 2001

Public Health
Disease Containment
Isolation:
Separation and confinement of individuals known or suspected (via signs, symptoms, or laboratory criteria) to be infected with a contagious disease , to prevent them from transmitting disease to others.
Source: Barbera, et al., 2001; Gostin 2000

Public Health
Disease Containment
Quarantine

Possible infection with contagious disease
Isolation

Confirmed infection or contagious disease

Behavioral Health Implications of Isolation/Quarantine
Behavioral Goals

Reduction of psychological distress

Compliance with containment measures
Stressors

Separation from loved ones

Fear of impending illness

Fear of death

Stigma

Social isolation

Behavioral Health Implications of Isolation/Quarantine
Strategies

Provide basic needs

Provide information as it becomes available

Maintain communication with loved ones

Provide access to media

Provide psychoeducation

Provide compassionate/empathic care

Provide behavioral health support

In Hong Kong and Singapore:

Mandatory quarantines implemented in large residential areas

50% of the population fled before quarantine could be enforced
In Canada:
 Voluntary “shielding” strategy implemented

Extensive public education

Home visits by doctors

Worked well
Source: Pilch, 2004


Citizens instructed to remain at home for several days or weeks

Self-imposed measure to contain or minimize an epidemic

Education, information, food, and access to home health care provided

Alternative to quarantine
Source: Pilch, 2004


Maintains normal routines

Keeps families together

Decreases traffic flow

Minimizes patient surge

Targets delivery of health services to persons developing symptoms

Minimizes restrictions on civil liberties
Source: Pilch, 2004

Behavioral Health Perspective:
Manage Contamination,
Isolation, and Quarantine
When dealing with special contingencies due to contamination or infection…
Plan for the behavioral needs of patients who are exposed or require decontamination or isolation.

Patient Care
Strategies
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
Plan
Prepare & Mitigate
Pre-event
Train Drill
Respond
Event
Recover
Post-event
Evaluate Activate Restore Evaluate

Goal: Maintain Ongoing
Inpatient Care

Maintaining Ongoing
Inpatient Care
“In a massive disaster, many chronically ill patients could lose access to their physicians or settings where they usually receive care or obtain medications.”
“In a disaster event, care for hospitalized patients may deteriorate.”
Source: JCAHO, 2003

Plan for Maintaining Care for
Existing Patients

Prepare to optimize care for inpatients

Prepare for early discharge

Prepare for patient transport
 Prepare for “graceful degradation” of care

Plan for Graceful Degradation

Treat and board patients in hallways.

Ration care and personnel contact as needed.

Provide protection from legal actions due to unavoidable delivery of substandard care during declared emergencies.
Source: JCAHO, 2003

Track patients within the hospital and across the community to achieve the highest-possible quality care and reunite family members

Behavioral Health Perspective:
Maintain Quality Patient Care
While accommodating a surge of incoming patients during a terrorist event…
Hospitals must maintain ongoing quality care for current patients and carefully manage degradation of care.