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Population Health for Nurses

32.5 The Nurse’s Role in Emergency Preparedness and Disaster Response

Population Health for Nurses32.5 The Nurse’s Role in Emergency Preparedness and Disaster Response

Learning Outcomes

By the end of this section, you should be able to:

  • 32.5.1 Explain the nurse’s role in emergency preparedness, disaster response, and disaster recovery.
  • 32.5.2 Compare the stages of disaster to the nursing process.
  • 32.5.3 Describe disaster triage.

Community health nurses are well positioned to respond in times of disaster and maintain a constant role across the disaster cycle of preparedness and national planning framework (APHN, 2014). From emergency preparedness to disaster recovery, they work with individuals, families, the community, and local administrators to promote health and well-being and to prevent illness (Siva & Prema, 2018). Community health nurses are not only acute-care providers or first responders, but they also maintain a long-term focus on a healthy community during the disaster phases. Their knowledge of and skills in epidemiology, determinants of health, community mapping, risk assessment, disease surveillance, community resources, health teaching, and mass education make them effective members of the disaster management team. Their relationships with and intimate knowledge of how people in the community will respond to a crisis and what resources they may use or benefit from make them trusted health care professionals during times of uncertainty (APHN, 2014; Siva & Prema, 2018).

As discussed, emergency preparedness is an essential role for the community health nurse. Having a workable plan that can be implemented in an immediate response to a disaster is critical. Community health nurses should be ready to expand their role in nonroutine practice areas during the response to a mass casualty event. The competencies expected of the community health nurse include emergency readiness and response and ensure the nurse’s ability to understand and execute the necessary skills and behaviors in the event of an incident (International Council of Nurses, 2019). Table 32.11 lists disaster competencies for the general professional nurse, or nurses who have completed undergraduate nursing education programs. The competencies fall within eight disaster management domains.

Domain Competency
  1. Preparation and Planning
  • Maintains a personal and professional preparedness plan
  • Participates in disaster exercises in the workplace
  • Maintains knowledge of available emergency resources, plans, policies, and procedures
  • Describes methods to assist vulnerable populations during a disaster response
  1. Communication
  • Uses disaster terminology correctly when communicating
  • Communicates disaster priority information promptly to appropriate individuals
  • Demonstrates basic crisis communication skills during disaster events
  • Uses culturally and linguistically appropriate resources to communicate with populations
  • Documents essential assessment and intervention
  1. Incident Management
  • Describes the national structure for response to a disaster
  • Uses disaster planning chain of command relevant to workplace and/or disaster drill
  • Contributes to post-event evaluation
  • Practices within license scope of practice during a disaster
  1. Safety and Security
  • Maintains safety for self and others throughout a disaster event
  • Adapts basic infection control practices to the available resources
  • Assesses self and others during a disaster event to identify the need for physical or psychological support
  • Uses PPE as directed during a disaster event
  • Reports possible risks to personal or others’ safety and security
  1. Assessment
  • Reports symptoms or events that might indicate the onset of an emergency or disaster
  • Performs rapid physical and mental health assessments based upon principles of triage and the type of disaster
  • Maintains ongoing assessment for needed changes in care in response to an evolving disaster
  1. Intervention
  • Implements basic first aid as needed by individuals in the immediate vicinity
  • Isolates persons at risk of spreading communicable conditions to others
  • Participates in contamination assessment or decontamination of individuals when directed through the chain of command
  • Engages clients, family members, or volunteers, within their abilities, to extend resources during disasters
  • Provides client care based on priority needs and available resources
  • Participates in surge capacity activities, such as mass immunization
  • Adheres to protocol for management of large numbers of deceased persons in a respectful manner
  1. Recovery
  • Assists in organization to maintain or resume functioning during and post disaster
  • Assists assigned clients to maintain or resume functioning during and post event
  • Makes referrals for ongoing physical and mental health needs
  • Participates in transition debriefing to identify personal needs for ongoing assistance
  1. Law and Ethics
  • Practices within nursing and emergency-specific laws, policies, and procedures
  • Applies disaster ethical framework in care
  • Demonstrates understanding of ethical practice during disaster response based on utilitarian principles
Table 32.11 Disaster Competencies for the General Professional Nurse (See International Council of Nurses, 2019.)

Stages of Disaster Response and Recovery

When communities face a disaster, the success of the response and recovery depends on a common, interoperable approach to sharing resources, coordinating and managing incidents, and communicating information (Homeland Security, 2019). The National Response Framework (NRF) provides foundational emergency management guidelines for response (Homeland Security, 2019). The National Incident Management System (NIMS) was developed by the Department of Homeland Security in 2004 within the NRF to establish a standardized set of processes and procedures that guides emergency responders at all levels of government organizations, nongovernmental organizations, and the private sector to conduct response operations (FEMA, 2017). The NRF and NIMS identify key roles and responsibilities at each stage of disaster response. The NRF can be partially or fully implemented when there is a threat or hazard, a significant event is anticipated, or in response to an incident (Homeland Security, 2019).

Disaster response and recovery occurs in stages that occur sequentially as the incident develops. These stages are grouped by activities with a common purpose so that emergency response is well organized and sequenced through specific intervals of an incident (HHS, 2012).

  • Stage 1: Incident Recognition—A rapid assessment of the situation is completed, and the organization decides that emergency-related support and response is needed.
  • Stage 2: Initial Notification and Activation—Initial notification and activation occur simultaneously. Appropriate organizations within the response system are notified of the incident. Urgent information is provided about the incident, and guidance is provided about the actions the community should take. Activation determines the response level to the incident and activates the emergency response procedures.
  • Stage 3: Mobilization—This is the movement of the organization from a state of inactivity or baseline operations to the required response level.
  • Stage 4: Incident Operations—This refers to all actions that address the response objectives following activation (other than mobilization and demobilization). The actions in this stage may be further divided into “initial” (or “immediate”) and “ongoing” categories.
  • Stage 5: Demobilization—This stage addresses the transition of resources from response activities back to baseline operations. Demobilization procedures are triggered as response objectives are achieved and resources are relieved of incident responsibilities.
  • Stage 6: Transition to Recovery and Return to Readiness—This stage is a return to a state of readiness for the next emergency.

The Nursing Process Applied to Disaster Response and Recovery

Public health nurses bring critical expertise to each phase of a disaster: mitigation, preparedness, response, and recovery. The practice of public health nursing is often more visible and better understood by the general public during the response and recovery phases, but their contribution is just as vital in the mitigation and preparedness phases, although probably underutilized. The increased involvement of public health nurses in disaster planning and response begins with their understanding of the comprehensive scope and standards of practice and follows with their striving to achieve individual competencies to better collaborate with others and contribute to emergency preparedness and response (Jakeway et al., 2008). Table 32.12 shows the phases of the disaster management cycle and provides examples of the nurse’s role in relation to the nursing process.

Disaster Phase Assessment and Analysis Planning Implementation Evaluation
Mitigation and Preparedness
  • Assess the community for individuals and populations at risk during disaster.
  • Assess the community for hazard vulnerability and identify hazards that create the greatest risk.
  • Assess community design and available resources for potential locations for sheltering, routes for evacuation, and locations, transportation, and resources to hold and process mass casualties.
  • Develop a plan to address needs of populations at risk during a disaster.
  • Create a plan to minimize hazard vulnerability, especially in those areas identified as high risk.
  • Collaborate with community members to plan for sheltering, evacuation, and mass casualty needs during disaster.
  • Conduct tabletop exercises or simulations of the plan to address the needs of populations at risk.
  • Implement a plan to minimize hazard vulnerability, such as increasing security and monitoring high-risk areas.
  • Conduct exercises to practice the plan for sheltering, evacuation, and mass casualty events.
  • Evaluate the tabletop exercises or simulations, identifying strengths, areas for improvement, and need for additional resources.
  • Evaluate the plan to minimize hazard vulnerability.
  • Evaluate sheltering, evacuation, and mass casualty plans, identifying strengths, areas for improvement, and need for additional resources.
  • Triage victims of a disaster.
  • Assess for risk for communicable disease.
  • Assess for health care needs of the community and current resources for response.
  • Develop a plan for triage, treatment, and transport to health care facilities.
  • Develop a plan to provide mass vaccination to the community.
  • Schedule nurses and emergency response team to provide triage care throughout the community in shifts.
  • Triage, treat, and transport clients to health care facilities.
  • Conduct a mass vaccination clinic.
  • Provide response care to the community in shifts.
  • Evaluate the triage, treatment, and transport plan to identify strengths, need for resources, and areas for improvement.
  • Evaluate the plan for mass vaccination and revise as needed to increase the number vaccinated.
  • Evaluate the shift schedule and revise as needed to ensure the health care team is not overworked or overstressed.
  • Assess the community for continued communicable disease risks.
  • Assess the community and health care workers for mental health needs.
  • Develop a plan to decrease communicable disease risks, such as education regarding food and water safety, eliminating standing water, and disposal of deceased animals.
  • Collaborate with community mental health workers to develop a plan to provide mental health care to the community and health care workers.
  • Provide education on disease risk and methods to decrease risk.
  • Refer individuals to mental health providers.
  • Evaluate the impact of the plan to decrease communicable disease risk.
  • Evaluate the plan to provide mental health services, identifying the need for additional resources, strengths, and areas for improvement.
Table 32.12 Nursing Process Applied to Disaster Management (See Association of Public Health Nurses, 2014; Jakeway et al., 2008.)

Mass Casualty Triage Systems

Response to mass casualty events often involves more victims than responding caregivers, requiring responders to sort victims categorically based on the degree of injury. Triaging during a mass casualty event is a dynamic process that requires disaster preparedness training. Medical responders to a mass casualty must triage victims differently than when caring for clients in a controlled setting, sorting victims based on severity of injury rather than treatment of injuries. This may seem counterintuitive to normal prehospital protocols. The goal of triage systems used in mass casualty events is to do the greatest good for the greatest number of people given limited available health care resources (Clarkson & Williams, 2023). Treatment during field triage is minimal, with the goal of moving clients away from the incident and toward resources that offer more comprehensive care. Victims should be reassessed and may be recategorized based on changes in their clinical status. The triage process should focus on clients’ rapid assessment and quick movement (Clarkson & Williams, 2023).

There are several triage systems used worldwide. The algorithms are similar and have a tightly structured approach. The following sections discuss the most common triage systems.

START Triage

The Simple Triage And Rapid Treatment (START) method was developed in 1983 by Hoag Hospital and Newport Beach Fire Department staff in California for rescuers with basic first-aid skills. START is the most widely used triage system in the United States for mass casualty incidents (Clarkson & Williams, 2023). START assesses the victim’s ability to obey commands, respiratory rate, and radial pulse or capillary refill.

The START triage system uses a color-coded tag method to categorize clients based on the severity of the injury and to guide transport. Triage tags allow responders to sort victims quickly and indicate the level of treatment needed efficiently. These colors are universally recognized and correspond to a predetermined set of physical assessment findings, so responders have a standardized way to tag victims. Red indicates that the person has a life-threatening injury that requires immediate treatment; yellow indicates that the person has a serious injury that can tolerate delayed treatment, and green indicates that the person has minor injuries and is considered “walking wounded.” The color black is used for those already deceased or imminently expected to expire. Figure 32.7 shows the decision tree for tagging victims based on assessment findings. Once victims are triaged and tagged, they should be moved to designated areas that serve as treatment and loading zones for transport to higher levels of care.

A yes or no flow chart provides yes or no questions to determine the status of clients when conducting mass casualty triage. The definitions of the triage categories are: expectant: client unlikely to survive given the severity of injuries, level of available care, or both. Palliative care and pain relief should be provided. Immediate: client can be helped by immediate intervention and transport. Requires medical attention within minutes (up to 60) for survival. Includes compromises to the client’s airway, breathing, and circulation. Delayed: client’s transport can be delayed. Includes serious and potentially life threatening injuries, but status not expected to deteriorate over the next several hours. And last, minor: client with relatively minor injuries. Status unlikely to deteriorate over days. May be able to assist in own care; walking wounded. The first question is if the client is able to walk. If the answer is yes, they are classified as minor and sent to secondary triage. If the answer is no, the next question is if they are spontaneously breathing. If the answer is no, the airway must be positioned. If spontaneous breathing does not occur, the client is labelled expectant. If spontaneous breathing does occur, the client is labeled immediate. If the client is able to spontaneously breathe on their own, the next question is what their respiratory rate is. If it is equal to or greater than 30, the client is labelled immediate. If it is less than 30, the perfusion is checked next. If the radial pulse is absent of capillaries refill more than every 2 seconds, the client is labelled immediate. If the radial pulse is present or the capillaries refill less than every 2 seconds, mental status is checked. If a client is not able to obey commands, they are labelled immediate. If they are able to obey commands, they are labelled delayed.
Figure 32.7 The START triage system uses a decision tree for tagging victims based on assessment findings. (See U.S. Department of Health and Human Services, 2023; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

SALT Triage

The Sort, Assess, Life-saving Interventions, and Triage/treatment (SALT) system is similar to the START system; however, it is more comprehensive and adds simple life-saving interventions during field triage (Clarkson & Williams, 2023).

  • SORT: Sort the walking, waving, and still. The responder asks all victims at the scene to walk to a designated casualty collection area if possible and wave an arm or leg if they need help. Those who cannot move or follow commands should be assessed first.
  • ASSESSMENT: Assessment and lifesaving interventions occur concurrently. Upon assessment of a victim with life-threatening injuries, the responder should intervene.
  • LIFE-SAVING INTERVENTIONS: If not time-intensive, simple techniques such as controlling major hemorrhages, opening airways, needle decompression, and auto-injector antidotes should be performed. Once the intervention is performed, the responder should assign a color-coded tag similar to the START system and move on to the next victim.
  • TREATMENT AND TRANSPORT: Once tagged, victims are moved to the designated casualty collection point for transport by emergency management services to higher levels of care.

START Triage Basics

This video gives an overview of how the START Triage algorithm is used during field triage.

Watch the video, and then respond to the following questions.

  1. How does the nurse provide rapid assessment using START triage?
  2. How should the nurse tag a client who passes all tests? How should a nurse tag a client who fails one test?
  3. What interventions do victims tagged as immediate receive?


JumpSTART is a modification to the START system to assess and triage pediatric victims up to 8 years old. This method considers the difference in normal respiratory rates for children up to age 8. If the child’s age is unknown, the responder should look for underarm hair in males or breast development in females as an indicator of adult age (Clarkson & Williams, 2022).

The differences in this algorithm include:

  • If a child is apneic with a pulse, open the airway and provide five rescue breaths. If breathing resumes, tag them as immediate (red). If apnea continues after five rescue breaths, they are given an expectant (black) tag.
  • Normal respiratory rates are more than 15 or less than 45. If respirations fall outside this range, tag them as immediate (red).
  • Neurological assessment is performed using the mnemonic AVPU (alert, responds to verbal stimuli, responds to painful stimuli, and unresponsive). Victims with abnormal posturing to painful stimuli or who are unresponsive are assigned an immediate (red) tag designation.

Unfolding Case Study

Part B: Disaster Management

Read the scenario, and then answer the questions that follow based on all the case information provided in the chapter thus far. This case study is a follow-up to Case Study Part A.

A major hurricane makes landfall in Juanita’s community, causing widespread damage, loss of electricity, flooding, and mass injury. The community activates the hurricane disaster plan and mobilizes the emergency response team. Juanita is dispatched with the first wave of emergency responders to assist in client triage on-scene. She tags victims using the START method for adults and JumpSTART for children and provides lifesaving interventions to red-tagged victims prior to moving them for transport.

The following day Juanita works at a shelter receiving community members displaced from their homes. She finishes set-up of the temporary health center, organizes and tracks supplies, assesses community members as they enter the shelter, and provides interventions to prevent communicable disease such as setting up handwashing stations, monitoring for signs of infection, and providing clean clothing, food, and water.

What action should Juanita complete prior to on-scene triage?
  1. Confirm victim transport has arrived
  2. Activate the Incident Command center
  3. Ensure the scene is safe
  4. Provide report to the emergency room
What finding will Juanita expect when assessing community members entering the shelter?
  1. Malnutrition
  2. Stress
  3. Communicable disease
  4. Confusion

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