Hurricane Preparedness Guide

Emergency Operations Plan

• Develop a written plan to facilitate recovery after a hurricane. Suggestions to include:
  • Purpose
  • Scope
  • Plan activation
  • Organization chart and roles
  • Communication Plan
  • Memoranda of Understanding
  • Continuity of Operations Plan
• Determine services available after the storm and how to triage appointments
• Develop downtime procedures with appropriate documentation
• Protect and back up essential documents with redundant methods
• Construct a memorandum of understanding for an alternate location to practice and to store vaccines
• Review insurance coverage to determine adequate coverage for the hazard and business disruption
• Identify patients medically dependent on technology or electricity
• Designate staff members to implement components of the disaster plan, such as dealing with facility issues, communication, operations, etc.
• Train employees on the emergency operations plan and developing their own family disaster plan
• Practice plan annually and update as necessary
• Record and update essential supplies and inventories regularly
• Become involved with local emergency preparedness planning
• Integrate plans with local hospitals and other clinics
• Educate patients on disaster preparedness and discuss contingency plans specific to the patient’s needs
• Develop your own family disaster plans

Communication Plan

• Detail how to communicate with staff, patients, and community in a written plan
• Periodically verify contact information for patients and staff
• Establish a database of key contacts needed for business continuation
• Practice handling inquiries from families and conflicting information
• Designate staff member to serve as the communication lead to provide timely and accurate information
• Create message templates that can be easily modified for communication
• Identify multiple communication methods to use after the storm

Disaster Office Kit

• Office supplies
  • Pens
  • Paper
  • Batteries
  • Extension cords
  • Tape
  • Toilet paper
  • Paper towels
  • Cleaning supplies
  • Plastic bags
• Stethoscope
• Battery-powered otoscope and ophthalmoscope
• Tongue blades
• Cotton-tipped swabs
• Gloves
• Masks
• Thermometer
• Sphygmomanometer
• Tape measure
• Portable Scale
• Saline solution
• Skin disinfectant
• Various types of bandages and gauze
• Suture kits, steri-strips, skin glue
• Lidocaine
• Medications
  • Ibuprofen
  • Diphenhydramine
  • Oral steroids
  • Albuterol nebulizer solution
• Syringes and needles
• Downtime documentation
• Sharps container
• Prescription pad
• Copies of credentials, licenses, and insurance information

Business Continuity of Operations Plan

• Perform business impact analysis and prioritize essential functions
• Identify documentation, contact information, agreements, and resources required during recovery. Resources include:
  • Staff
  • Office space
  • Technology (internet, equipment, computer, etc.)
  • Vital records
  • Inventory and supplies
  • Utilities
  • Vendors
• Develop recovery strategies and alternate means to attain resources disrupted by the storm
• Identify recovery team and develop relocation plans
• Establish an order of succession to predetermine roles and responsibilities
• Cross-train staff members on essential tasks and explore collaborative agreements to share staff with other clinics
• Review financial support and payroll backup
• Determine alternate billing and collection options

Initial alert: 36-48 hours

• Listen to the local news for weather updates
• Go over flood zones, evacuation zones, and evacuation routes
• Review Family Disaster Plan, Emergency Operations Plan, and insurance coverage
• Ensure data has been backed up
• Alert staff members and patients
  • Help families with children dependent on electricity or special needs
• Inspect disaster kit for missing items

Approaching: 18-36 hours before

• Prepare office
  • Cover windows with storm shutters or plywood
  • Unplug electronics and cover with plastic
  • Move objects off the ground
  • Arrange pay for employees beforehand
  • Bring displays from outside
  • Secure first floor access with sandbags
• Follow instructions of local authorities about evacuation
  • Take disaster kit
  • Consider practicing at an alternate location

Near: 6-18 hours before

• Check the latest weather updates often
•  Charge cell phones, computers, and other electronics to be able to work remotely

Immediately before: 0-6 hours

• Stay home if not in area of evacuation
• Do not go outside until storm is over
• Stay away from windows
• Check the latest weather updates often
• Be ready if ordered to leave

Short Term

• Take care of yourself and family after the storm
  • Make sure all needs are met before returning to practice
• Check on the status of staff and families
  • Determine if they need additional resources
• Initiate emergency operations plan, communication plan, and continuity of operations plan
• Survey the condition of the clinic if the building can be safely reached and local authorities have allowed access to the area
  • Inspect building and photograph damage
  • Salvage resources
  • Determine need to relocate
• Carry identification and licensing information
• Communicate with patients and staff about the current status of the clinic and information about future operations
• Establish services available after the storm

Long Term

• Fully recover all essential functions
• Submit claims to insurance and identify need for financial assistance
• Invite staff to submit comments on improving plans and response
• Address recommendations and corrective actions in the improvement plan
• Update and practice plans

Mold

• Route and sources of exposure
  • Buildings wet for >48 hours in the aftermath of hurricane and associated flooding
  • Route of exposure by inhalation, skin contact, and ingestion of airborne spores or mycelial fragments
• Clinical Effects
  • Allergic and hypersensitivity reactions
    • Allergic rhinitis
    • Asthma exacerbations
    • Allergic dermatitis
    • Allergic bronchopulmonary aspergillosis (ABPA)
    • Hypersensitivity pneumonitis
    • Allergic fungal sinusitis (AFS)
  • Irritant reactions
    • Cough
    • Skin irritation
    • Conjunctivitis
  • Toxic reactions
    • Organic dust toxic syndrome
    • Pulmonary hemorrhage in infants
• Diagnosis
  • Environmental assessment with inquiry about mold and water damage
  • Laboratory and diagnostic tests as deemed appropriate
• Treatment
  • Removal from the environment
  • Rectifying conditions in the building
  • Medical treatment for symptoms and underlying conditions, such as:
    • Antihistamines
    • Inhaled nasal corticosteroids
    • Inhaled pulmonary corticosteroids
• Prevention of Exposure
  • Avoid areas with contamination
  • Use personal protective equipment
  • Keep hands, skin, and clothing clean
  • Do not allow children back into building until cleanup is finished

Mosquitoes

• Route and sources of exposure
  • The types of mosquitoes spreading viruses can increase 2 weeks to 2 months after a hurricane
  • Endemic areas of vector-borne diseases enhance potential exposure to malaria, dengue, chikungunya, West Nile, and zika
• Clinical Effects
  • Flu-like febrile illness with myalgias, arthralgias, and rash
  • Special characteristics
    • Chikungunya most likely involves small joints
    • Dengue can lead to capillary leak syndrome and severe bleeding
    • West Nile may be neuroinvasive, causing flaccid paralysis and/or meningoencephalitis
    • Pregnant women infected with Zika have an increased risk of microcephaly and malformations
• Diagnosis
  • Environmental assessment with inquiry about exposure to mosquitoes
  • Laboratory and diagnostic tests as deemed appropriate
• Treatment
  • Medical treatment for symptoms and underlying conditions
• Prevention of Exposure
  • Prevent bites
    • Wear long sleeves and pants
    • Use insect repellants approved by the Environmental Protection Agency (EPA)
  • Babies and children
    • Cover legs and arms with clothing
    • Cover strollers and baby carriers
    • No insect repellants on children < 2 months of age
    • No products with oil of lemon eucalyptus (OLE) or para-menthane-diol (PMD) on children < 3 years of age
  • Get rid of standing water
  • Drain puddles of water or fill with dirt
  • Repair holes in screens or gaps in walls, doors, and windows

Flood Waters

• Route and sources of exposure
  • Flood water can be contaminated by waste, sewage, chemicals, bio-toxins, heavy metals, and water-borne pathogens
  • A number of hidden hazards in the flood water from trees, branches, electrical wires, broken glass, and other sharp objects
  • Exposure by skin contact, inhalation, and ingestion
• Clinical Effects
  • Cutaneous infection
    • Common: Staphylococcus aureus, Streptococcus pyogenes
    • Less common: Aeromonas spp., Vibrio spp., Shewanella spp., Leclercia adecarboxylata, Chromobacterium violaceum, Clostridium tetani, fungi, mycobacteria
  • Aspiration pneumonia/pneumonitis
  • Gastroenteritis
    • Shigella, Salmonella, Vibrio cholerae, enterotoxigenic Escherichia coli
  • Leptospirosis
  • Hepatitis A or E infection
• Diagnosis
  • Environmental assessment with inquiry about exposure to flood water
  • Laboratory and diagnostic tests as deemed appropriate
• Treatment
  • Antibiotics indicated for cellulitis and soft tissue infections
  • Update tetanus prophylaxis
  • Medical treatment for symptoms and underlying conditions
• Prevention of Exposure
  • Do not swim or drive through floodwaters
  • Do not allow children to play in floodwaters
  • Avoid exposure to open wounds
  • Wash hands with clean water
  • Drink bottled water
  • Use bottled water to mix baby formula and for cooking
  • Bathe children with bottled water until tap water considered safe

Carbon Monoxide Poisoning

• Route and sources of exposure
  • Exposure by inhalation
  • CO poisoning increases due to loss of electricity
  • Sources of exposure:
    • Gasoline-powered generators and equipment
    • Charcoal or propane grills
    • Gas appliances
    • Tobacco smoke
• Clinical Effects
  • Clinical presentations are highly variable and do not correlate with the level of exposure. Symptoms include:
    • Headache
    • Dizziness
    • Fatigue
    • Lethargy
    • Weakness
    • Drowsiness
    • Nausea and emesis
    • Skin pallor
    • Dyspnea
    • Palpitations
    • Confusion
    • Irritability
    • Loss of consciousness
    • Death
  • Lethargy and syncope are frequently reported in pediatric patients
  • Delayed neuropsychological sequelae
    • Memory impairment
    • Decreased attention
    • Reduction of executive functioning
• Diagnosis
  • Environmental assessment with inquiry about generator use and mode of cooking
  • Other household members with the same non-specific symptoms
  • Carboxyhemoglobin (COHb) level
• Treatment
  • Removal from environment
  • Administration of 100% oxygen
• Prevention of Exposure
  • Limiting exposure by following safety guidelines and manufacturer’s guidelines
  • Never operate indoors or in poorly ventilated areas
  • Use smoke detectors and CO detectors

Extreme Heat

• Route and sources of exposure
  • Inadequate cooling in buildings due to loss of electricity
  • Decreased cooling ability and increased risk of hyperthermia with higher humidity
• Clinical Effects
  • Injuries resulting from heat
    • Heat exhaustion
    • Heat cramps
    • Heat stroke
  • Systemic effects of heat
    • Neurologic – Coma, seizures
    • Cardiovascular – Tachycardia, cardiovascular collapse
    • Musculoskeletal – Rhabdomyolysis
    • Metabolic – Metabolic acidosis
    • Respiratory – Tachypnea
• Diagnosis
  • Environmental assessment with inquiry about amount of time spent outside and associated activity
  • Rectal temperature
  • Laboratory and diagnostic tests as deemed appropriate
• Treatment
  • Rest, cooling, and hydration with fluids containing electrolytes
  • Aggressive cooling techniques needed for heat stroke, such as cool water immersion and IV hydration
• Prevention of Exposure
  • Avoid excessive activity during extreme temperatures
  • Adequate hydration
  • Access to reliable air conditioning
  • Never leave children unattended in vehicles

Animal Hazards

• Route and sources of exposure
  • Animal bites occur from displaced and frightened animals
  • Most animal bites occur within 72 hours after the hurricane and wane to baseline in the following weeks
  • Top animal bites result from dogs, cats, and snakes
  • Snakes are typically pit vipers
    • Rattlesnakes
    • Copperheads
    • Cottonmouth water moccasins
    • Coral snakes
• Clinical Effects
  • Animal bites
    • Typically involve extremities
    • Wide range of injuries: abrasions, scratches, open lacerations, deep puncture wounds, crush injuries, tissue and bone avulsions
    • Variable symptoms: swelling, local pain, hemorrhage, cellulitis, numbness, and tingling
  • Snake envenomation may include:
    • Severe local pain
    • High compartmental pressure and swelling
    • Coagulopathy
    • Myonecrosis
    • Changes in heart rate and rhythm
    • Shock
    • Multiorgan failure
• Diagnosis
  • Environmental assessment with inquiry about exposure and identification of animal hazard
  • Laboratory and diagnostic tests as deemed appropriate
  • Call poison control center for further guidance (1-800-222-1222)
• Treatment
  • Irrigation of wound
  • Examine for bone fracture and nerve damage
  • Update tetanus prophylaxis
  • Assess for rabies exposure and administer rabies vaccine and rabies immunoglobin, if necessary
  • Evaluate need for pit viper antivenom
  • Antibiotics if indicated
• Prevention of Exposure
  • Do not corner displaced animals
  • Teach children not to approach unknown animals and to be careful around pets after the storm
  • Remove food and water sources that can be used by displaced animals
  • Throw away trash and debris as soon as possible
  • Snakes may swim in water to get to higher ground
  • Avoid putting hands and feet in places not able to be visualized
  • Call local authorities for help removing animals from home

 

– Contact Poison Control Center or Regional PEHSU for other environmental hazards –

U.S. Department of Housing and Urban Development	1-800-955-2232
U.S. Postal Service	1-800-275-8777
Social Security Administration	1-800-772-1213
Medicare and Medical Issue	1-800-633-4227
Small Business Administration	1-800-659-2955
Federal Emergency Management Agency (FEMA)	1-800-621-FEMA or TTY 1-800-462-7585
FEMA, Open Emergency Shelter	Text SHELTER and zip code to 43362
SAMHSA’s Disaster Distress Hotline	1-800-985-5990 or text TalkWithUs to 66746
National Suicide Prevention Lifeline	1-800-273-TALK (8255)
Salvation Army	1-800-758-2769
American Red Cross	1-800-RED CROSS / 1-800-733-2767
American Red Cross, hurricane or any disaster registry/welfare	1-866-GET-INFO or online at RedCross.org/SafeandWell
Poison Control	1-800-222-1222
Emergency Services	911
National Flood Insurance	1-800-720-1090

Before a Disaster

1. American Academy of Pediatrics. (2013). Preparedness Checklist for Pediatric Practices. Retrieved from https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Documents/PedPreparednessChecklist1b.pdf
2. S. Department of Labor Occupational Safety and Health Administration. (2001). How to Plan for Workplace Emergencies and Evacuations. Retrieved from https://www.osha.gov/Publications/osha3088.pdf
3. Morehouse School of Medicine. (n.d.). Emergency Preparedness Toolkit for Primary Care Providers. Atlanta, Ga.
4. (n.d) Business Continuity Plan. Retrieved from https://www.ready.gov/business/implementation/continuity. During a Disaster

After a Disaster

5. American Academy of Pediatrics. (n.d.). AAP Disaster Recovery Checklist. Retrieved from https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/disaster-recovery-checklist.aspx.
6. (n.d.). Health Care Provider After Action Report Improvement Plan. Retrieved from https://asprtracie.hhs.gov/technical-resources/resource/185/health-care-provider-after-action-report-improvement-plan-aar-ip.

Environmental Hazards

7. Centers for Disease Control and Prevention. (2006). Mold Prevention Strategies and Possible Health Effects in the Aftermath of Hurricanes and Major Floods. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5508a1.htm.
8. University of Connecticut Health Center Division of Occupational and Environmental Medicine Center for Indoor Environments and Health (2004). Guidance for Clinicians on the Recognition and Management of Health Effects related to Mold Exposure and Moisture Indoors. Retrieved from https://health.uconn.edu/occupational-environmental/wp-content/uploads/sites/25/2015/12/mold_guide.pdf
9. Etzel, R. A., & Balk, S. J. (2019). Pediatric Environmental Health (4th ed.). Itasca, IL: American Academy of Pediatrics.
10. Warner, G. S. (2010). Increased Incidence of Domestic Animal Bites following a Disaster Due to Natural Hazards. Prehospital and Disaster Medicine, 25(2), 187–190. doi: 10.1017/s1049023x00007962
11. Wozniak, E. J., Wisser, J., & Schwartz, M. (2006). Venomous Adversaries: A Reference to Snake Identification, Field Safety, and Bite-Victim First Aid for Disaster-Response Personnel Deploying Into the Hurricane-Prone Regions of North America. Wilderness & Environmental Medicine, 17(4), 246–266. doi: 10.1580/06-weme-co-005r.1
12. Paterson, D. L., Wright, H., & Harris, P. N. A. (2019). Health Risks of Flood Disasters. The Pediatric Infectious Disease Journal, 38(3), 328. doi: 10.1097/inf.0000000000002260
13. World Health Organization. (2012, April 13). Flooding and communicable diseases fact sheet. Retrieved from https://www.who.int/hac/techguidance/ems/flood_cds/en/index1.html.
14. Huntington, M. K., Allison, J., & Nair, D. (2016, October 1). Emerging Vector-Borne Diseases. Retrieved from https://www.aafp.org/afp/2016/1001/p551.html.