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Transcript of Disaster Behavioral Health Awareness Training for Health Care Professionals Copyright © 2004: All...
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