Disaster Planning Nursing CE Course

2.0 ANCC Contact Hours AACN Category C

Syllabus

Upon completion of this activity, participants should be able to:

  1. Define disaster and mass casualty
  2. Identify the components and goals of a disaster plan
  3. Discuss the steps and goals of a disaster/mass casualty response
  4. Explain the nurse’s role in disaster planning and disaster/mass casualty response
  5. List additional disaster preparedness and disaster/mass casualty response resources for the learner

Purpose

The purpose of this course is to provide nurses with an overview of disaster preparedness education and evidence-based practice surrounding disaster planning and disaster/mass casualty response.

 The occurrence of natural and manmade disasters, from weather-related events to mass causality incidents, continues to rise. In 2017, the United States experienced wildfires in California and three major hurricanes, Harvey, Irma and Maria (Hanes, 2016; Veenema, 2018). Disasters and mass casualty incidents differ from other types of emergencies due to their large scale and probability of resulting in mass casualties (Rebmann, 2014).

Both nationally and globally, nurses comprise the largest group of health care providers. Traditionally, nurses in the military and public health sector have taken the lead in disaster and humanitarian response efforts. In today’s world, competency-based disaster preparedness education and training is needed for all nurses, regardless of practice setting (Cipriano, 2018; Kalanlar, 2019).

According to Veenema and colleagues (2017) “the U. S. needs a national nursing workforce –both civilian and uniformed services—that has the knowledge, skills, and abilities to respond to any disaster…in a timely and appropriate manner no matter where they occur in the world” (p. 2).

Disaster

    The United Nations Office for Disaster Risk Reduction (UNDRR, 2017) defines a disaster as:

A serious disruption of the functioning of a community or a society at any scale due to hazardous events interacting with conditions of exposure, vulnerability, and capacity, leading to one or more of the following: human, material, economic and environmental losses and impacts.

Disasters can be classified as natural disasters, man-made disasters, internal disasters, or external disasters. Natural disasters are caused by the environment and are weather-related. Examples of natural disasters include tsunamis, floods, tornadoes, earthquakes, and hurricanes. Man-made disasters are caused by humans and some examples include chemical spills, fires, transportation accidents, bioterrorism, and acts of war. Some disasters, such as the refugees who evacuated from Syria, result from a combination of causes, including political unrest, drought, famine, and disease. Healthcare facilities categorize disasters as either internal disasters or external disasters. Internal disasters cause a disruption in the ability of the facility to function normally. A power failure or a facility fire are examples of internal disasters. External disasters, such as a tornado or a plane crash, occur outside of the healthcare facility. Often, the resulting number of casualties can overwhelm the hospital’s resources, such as available supplies, equipment, beds, or staffing (Gebbie & Qureshi, 2018; Rebmann, 2014).  

Mass Casualty

    Consider the following scenario. You are one of several staff nurses working in a large urban medical center emergency room. Triage in the emergency room setting prioritizes patients in three categories: emergent, urgent, or nonurgent. The focus of care is to use all available resources to care for patients in the emergent category, who are acutely ill and present with life-threatening conditions (Gilroy, Tanabe, Travers, & Rosenau, 2018). In the middle of your shift, you are notified that a large commercial jet has crash-landed at the local airport. The emergency room expects to receive an influx of patients who have been injured in that crash. As a result, your facility activates its disaster plan and you prepare to respond to a mass casualty incident.

A mass casualty incident is defined as “an event where the number of casualties exceeds the available resources” (Markinson & Losinski, 2019, p. 61). Surge capacity is the community or healthcare facility’s ability to effectively care for an increased number of patients during a disaster or mass casualty incident (Hanes, 2016). The plan of care in responding to a mass casualty incident is to prioritize procedures and resources to save the greatest number of lives. According to the U. S. Department of Health and Human Services Chemical Hazards Emergency Medical Management (2019) and Markinson and Losinski (2019), triage in a disaster or mass casualty incident uses four triage categories:

  • Green tag color: Minor
    • Victim has minor injuries, “walking wounded”, and may be able to assist with own care. Status unlikely to deteriorate over days.
  • Yellow tag color: Delayed
    • Victim has serious injuries, may require surgery, and status unlikely to significantly deteriorate over several hours.
  • Red tag color: Immediate
    • Victim requires medical attention within minutes up to one hour. Injuries are severe but potentially reversible such as airway obstruction, accessible hemorrhage or emergency amputation.
  • Back tag color: Expectant
    • Victim unlikely to survive due to severity of injuries, level of available care, or both. Should receive comfort care.

Disaster Planning

    Disaster planning can be conceptualized using the disaster cycle. The disaster cycle consists of five elements: planning, preparedness, mitigation, response and recovery (Krau, 2016). Disaster planning is the first element in the disaster cycle. The goal of disaster planning is best expressed by Sharon Stanley, former chief nurse of the American Red Cross, who stated “disaster planning isn’t about putting something on paper. It’s about bringing together all stakeholders, ensuring they understand their roles and relationships, and determining together how they can keep their population safe and well” (Trossman, 2017).

    The Federal Emergency Management Agency Strategic Plan (FEMA, 2018c) is a framework for supporting the United States before, during, and after disasters occur. The FEMA Strategic Plan 2018-2022 has three goals which address U. S. disaster planning and preparedness:

  1. Build a culture of preparedness: everyone should be prepared when a disaster occurs.
  2. Ready the nation for catastrophic disasters: organize the best scalable and capable incident response workforce, enhance intergovernmental coordination, posture FEMA and the whole community to provide life-saving resources.
  3. Reduce the complexity of FEMA: promote simpler, less complex processes to support individuals and communities.

    The FEMA Strategic Goals support the mission to prepare and plan for disasters in the United States and provide a national scope for disaster preparedness goals (FEMA, 2018c).

Personal Disaster Plan

    Disasters or mass casualty incidents can occur suddenly with little to no warning, and nurses may be called upon to respond to and provide care to disaster victims. In order to be able to focus on caring for patients in a disaster, each nurse needs to have an up-to-date personal disaster plan that can be implemented to keep them and their family safe during a disaster. Nash (2015) completed a pilot study on nurses’ personal preparedness for disaster response and findings indicated that “although nurses are essential caregivers in disaster response, many are not prepared personally to report to the workplace during a disaster situation” (p.425). 

The first step in developing a personal disaster plan is to familiarize yourself with the types of disasters that can occur within your community. Consider the following questions: Do you live in an area that experiences weather-related disasters such as hurricanes or tornadoes? Are there industries in your community that produce, store or transport hazardous materials?  Communication is a key element of a personal disaster plan. Teach children how to call 911. Have a communication plan for how family members would stay in contact if you were separated in a disaster. Talk with your family members about potential emergencies (natural disaster, fire) and how to respond to each, including evacuation routes. Establish emergency meeting places outside of your home, in your neighborhood, to use if you have to evacuate. Choose a friend or family member who lives out of state as an emergency contact for family members to call and check-in. During an emergency, texting is preferable over phone calls as phone lines need to be kept clear for first responders. FEMA (2018a) has a Family Emergency Communication Plan template with wallet-sized cards available on their website. Each family member is advised to carry a copy of the completed family emergency communication plan in their backpack or wallet (FEMA, 2018a; Veenema, 2018a).

     Personal disaster planning also includes familiarizing yourself with your employer’s and your children’s school’s emergency response plans. Make sure that homeowners’ insurance, flood insurance, and health insurance policies are current and premiums are paid on time.  If your family needs to evacuate when a disaster strikes, be sure they take important documents, such as birth certificates and insurance policies with them. It is also important to have cash, loose change, and a credit card on hand to cover expenses in the event of an evacuation. If the disaster has caused power failures, credit card machines will not work. Plan ahead for any family member who has special needs, such as those who require prescription medications or have vision, hearing or mobility impairments. Prepare for the safety of your pets during a disaster as pets, other than service animals, are often not permitted in shelters. Maintain a disaster supply kit containing nonperishable food, water, and supplies for at least 3 days and store the kit in a grab-and-go location.  Consider keeping an additional disaster supply kit at work. Assemble and maintain a first aid kit for your home and each vehicle. Gather additional emergency supplies: a portable battery powered radio or weather radio, flashlight(s) with extra batteries, matches in a waterproof container, tools (wrench, pliers, shovel), compass, kitchen items (manual can opener, household bleach, paper cups and plates, utensils). Kits should include at least one complete change of clothing and footwear as well as pillows, blankets and/or sleeping bags for each family member (FEMA, 2018a; Veenema, 2018a).

Healthcare Facility Disaster Plan

     A healthcare facility disaster plan is a written plan that addresses four key components: resource management (supplies and staffing), communication systems and methods, reporting structure, and patient management. Best practices for writing a healthcare facility disaster plan focus on using a multiagency, interdisciplinary collaborative process, endorsing input from all key stakeholders.  The planning committee tasked with writing the disaster plan should include representatives from nursing administration, infection control, hospital epidemiologist, medical staff, security, housekeeping, central supply, risk management, dietetics, respiratory therapy, occupational therapy, local emergency management, and public health. The size of this group may vary depending upon the size of the healthcare institution. Once a disaster is on the horizon or has occurred, resource management is of key concern, and includes planning for, allocating, and distributing resources. Resources include supplies, equipment, and staff necessary to effectively respond to a disaster or mass casualty incident. Key considerations include on-hand equipment, backup equipment, pharmaceutical supplies, backup pharmaceutical supplies, available staff, backup staff, and facility surge capacity (Rebmann, 2014).

Community Disaster Plan

    A community disaster or emergency management plan is put in place during or after a mass casualty incident encompasses the community as a whole. Like healthcare facility disaster or emergency management plans, a community disaster plan is collaborative and encourages representation and input from all key stakeholders, such as first responders, law enforcement, public health, and other response agencies within the community. Since some disaster/mass casualty incidents involve infectious agents, it is critical to include infection preventionists, whom are often nurses, on the team responding to a community disaster or mass casualty incident (Rebmann, 2014).

Principles of Disaster Planning

    There ae two distinct approaches to disaster planning; the all-hazards approach and the agent-specific approach. The agent-specific approach is geared toward disasters or threats that are likely to occur in a certain geographic location, such as tornadoes in Oklahoma or hurricanes in Florida. Healthcare facilities located near a nuclear power plant or large chemical manufacturing facility may elect to use an agent-specific approach in writing and updating their disaster plan. The all-hazards approach, recommended by FEMA (2016, 2018c), is a more comprehensive disaster planning method that includes disaster planning and management components common to all types of disasters, in order to make the best use of resources. Initial response to a disaster or mass casualty incident occurs on the local level. Additional resources from surrounding communities, state, or federal government are requested and obtained depending upon the scope and nature of the disaster or mass casualty incident. The all-hazards approach to disaster planning is a community-wide effort which encourages the whole community to work together in planning for and responding to disasters. The whole community concept includes: local, state and national government, nongovernmental entities (religious groups, private businesses, nonprofits), and public health. (FEMA, 2016; Sledge & Thomas, 2019; Veenema, 2018c).

    The UNDRR (2017) facilitated the development of the Sendai Framework for Disaster Risk Reduction, which is a global policy that focuses on risk reduction in order to decrease the impact of a disaster using an all-hazards approach to planning (Atisi-Selmi, Egawa, Sasaki, Wannous, & Murray, 2015). Bearing in mind that disasters vary in size and onset, the Sendai Framework addresses disaster impact using the following terms:

  • Small-scale disaster: a type of disaster affecting local communities which require assistance beyond the affected community.
  • Large-scale disaster: a type of disaster affecting a society which requires national or international assistance.
  • Frequent disasters: impact can be cumulative or chronic on a community or a society.
  • Slow-onset disaster: emerges gradually over time.
  • Sudden-onset disaster: triggered by a hazardous event that emerges quickly or unexpectedly (UNDRR, 2017).

Components of a Disaster Plan

A key component to disaster planning is assessment, which should include hazard identification, vulnerability analysis, and risk assessment (Veenema, 2018c). In order to be able to design an effective disaster response, a thorough assessment of hazards, vulnerabilities, and risks is essential. According to Atisi-Selmi and colleagues (2015):

“Progress in disaster risk reduction research has shown that it is often not the hazard that determines a disaster, but the vulnerability, exposure, and ability of the population to recover from its effects…the identification, assessment and ranking of vulnerabilities and risks becomes critical” (p. 165).

The first step in developing a disaster plan is hazard identification and vulnerability assessment, which strive to examine the region-specific hazards, such as floods, tornadoes, earthquakes, or hurricanes, and assess the likelihood of mass casualty incidents. According to Veenema (2018c), hazard identification and vulnerability assessment are critical to predict the location, timing and magnitude of future disasters. 

 When completing a thorough disaster risk assessment, it is possible to mitigate the severity of a potential disaster’s impact upon a healthcare facility or a community. The overall goal of mitigation is to lessen the impact of a disaster by removing hazards and relocating vulnerable populations. In a disaster that is likely to include high winds, mitigation strategies include placing outdoor furniture indoors and boarding up windows or applying hurricane shutters. Additional mitigation strategies in hurricane prone states, such as Florida, Texas, Mississippi or Louisiana include evacuating residents of a long-term care facility or a hospital in a low-lying, flood-prone area to another facility in a nearby community that is located on higher ground. Unlike tsunamis, earthquakes or tornadoes, hurricanes have a watch and a warning period which allows those affected, including healthcare facilities, to evacuate patients and residents to other healthcare facilities that are situated on higher ground (FEMA, 2016, 2018c; Veenema, 2018c). In the California wildfires, Hanes (2016) cited the evacuation of a hospital and a long-term care facility in San Diego to mitigate the consequences of the California wildfires. McSweeney-Feld and Lane (2019) emphasize the importance of disaster planning and organizational readiness in long-term care facilities, including the critical importance of allowing at least 48 hours for a facility evacuation in the event of a hurricane. Vulnerable populations include the homeless, minorities, elderly, infants, children, pregnant women, and individuals with mental illness or disabilities. The healthcare needs of vulnerable populations must be addressed in all aspects of disaster planning, response, and recovery (Davis, Hansen, Peek, Phillips & Tuneberg, 2018).

Disaster/Mass Casualty Response and Recovery

    Once a disaster or mass casualty incident has occurred, the response plan is activated. Depending upon the extent or impact of the incident, issues with resource management and alterations in the usual standards of care may occur. During the response phase of a disaster or mass casualty incident, available resources will quickly become depleted. During the planning phase, memoranda of understanding between the facility, other healthcare facilities, and vendors may help to alleviate the depletion of resources.  Even with the most thorough disaster and mass casualty response planning, the extent and scope of the disaster or mass casualty response may necessitate implementing crisis standards of care for allocating limited resources. This is where the focus of triage and management of care transitions toward ‘doing the greatest good for the most individuals,’ and disaster triage is implemented instead of the traditional emergency room triage methods. The response phase of the disaster cycle concentrates efforts on emergency relief, first aid, and restoring damaged systems such as power, transportation, or communication. The healthcare team should focus on providing care and basic life necessities (food, water, shelter) for victims. (Rebmann, 2014; Veenema, 2018c). 

    The recovery phase of the disaster cycle focuses on returning the healthcare facility and the community to normal. This can encompass restoring power and communication capabilities, repairing roads and damaged structures, and returning a healthcare facility to its normal operations. Disaster and mass casualty response efforts often entail situations that cause affected patients and/or staff members to experience some degree of mental anguish, such as moral distress, survivor guilt, or post-traumatic stress. According to the Centers for Disease Control and Prevention (CDC, 2018), responding to disasters is both rewarding and challenging for nurses and other healthcare providers. Stressors that can affect individuals who respond to a disaster or mass casualty incident can lead to risk of personal harm, intense workloads, life-and-death decision making, and separation from family members. In the disaster planning and preparation phase, nurses must be briefed about their roles and responsibilities during a disaster response (CDC, 2018). 

The Nurse’s Role in Disaster Planning 

    As the largest occupational group of healthcare professionals, it is critical that nurses take an active role in disaster planning, response and recovery. Nurses with community health expertise, including public health nurses, home health nurses and school nurses need to be involved in community risk assessments, and the disaster planning process. Community disaster plans should align with the U.S. National Response Framework which supports the National Preparedness Goal of “a secure and resilient nation with the capabilities required across the whole community to prevent, protect against, mitigate, respond to, and recover from threats and hazards that pose the greatest risk” (FEMA, 2016)

    Nurses in healthcare facilities who function in leadership roles, including shift supervisors, nurse managers, staff development educators, and infection control personnel should have a seat at the table along with other department managers when a disaster plan is written or updated. Every staff nurse must know the location of the facility disaster plan and have had the opportunity to read and review the plan during their onboarding or facility orientation period (Rebmann, 2014).

    As discussed earlier, each nurse needs to have a personal disaster plan in place that addresses what their family members need to do in the event of an in-home emergency or a disaster. According to Sathasivan (2019) “as residents of the area impacted by a disaster, nurses are concerned about the safety of their own families and homes” (p. 9). Having a personal/family disaster plan in place will enable nurses to report to work in the event of a disaster or mass casualty incident and know that their family members have a plan in place to keep them safe (CDC, 2018).

    Personal readiness also includes disaster and mass casualty response education and training. In addition to being familiar with the employer’s facility disaster plan, nurses need to be knowledgeable about the disaster response cycle, disaster triage, and nursing roles during a disaster or mass casualty incident. Disaster preparedness education can include curriculum in a pre-licensure or graduate-level nursing program, continuing education courses, and/or experiential learning such as through simulation or disaster drills (Kalanlar, 2019; Sathasivan, 2019; Veenema et al., 2017). 

    Self-care and resilience are important aspects of personal readiness that nurses can address during the disaster planning and preparedness phase. Having a personal/family disaster plan in place to promote the care and safety of family members during a disaster is one aspect of self-care. Resilience is enhanced when nurses are made aware during the disaster planning and preparedness phase that they will be working longer hours, with fewer breaks, and caring for more patients. It is advised that nurses use the buddy system and keep an eye on each other, encourage each other to take breaks to eat, sleep, or exercise. Other self-care techniques include working in teams, journaling, engaging in deep breathing and relaxation exercises, limiting working hours to no longer than twelve-hour shifts when possible, and avoiding or limiting caffeine and alcohol consumption (CDC, 2018).

The Nurse’s Role in Disaster/Mass Casualty Response

    The American Nurses Association (2017) issued a brief addressing the key ethical and legal concerns faced by nurses in a disaster or mass casualty response. The American Nurses Association Code of Ethics, provision 2 states that “the nurse’s primary commitment is to the patient” and provision 5 states that “the nurse owes the same duty to self as to others.” Consequently, the nurse has an ethical obligation to care for self and for others. In a disaster response situation, there can be an ethical conflict of obligation where the nurse must decide how much high-quality care can be delivered to others, while not sacrificing self-care. 

    Nurses need to be well versed in the four stages of triage in a disaster or mass casualty incident. Experienced nurses may be called upon to assist with disaster triage during a mass casualty incident. Once triage has been accomplished, nurses need to understand the assigned triage category, the severity of injury, and subsequent prioritization of nursing care. Infection prevention precautions and surveillance may need to be implemented in a disaster or mass casualty event involving an infective agent (Rebmann, 2014).

    Davison (2019), an experienced nurse who has deployed five times to provide care in a disaster response, wrote an article on a nurse practitioner’s perspective on the “cost” of Hurricane Florence, particularly as it effected the area’s most vulnerable populations. She noted that “depression, asthma, diabetes, and hypertension were often exacerbated by the stress, anxiety, homelessness, food insecurity, and difficulty accessing care…the effects last for years and vulnerable populations suffer the most” (p. 8). 

In the disaster recovery phase, infrastructure is restored and the community and affected healthcare facilities begin to resume normal operations. The nurse’s role during disaster recovery includes providing care, withdrawal from the disaster scene, monitoring the long-term physical health of disaster victims, debriefing staff and revising the disaster plan based on lessons learned during this disaster response and recovery. Nurses need to be willing to assume leadership roles in disaster preparedness and response policy making on the local, state, and federal levels. Nurses who have taken an active role in planning for, responding to, and recovering from disasters can use those experiences to influence and improve disaster preparedness and response for future events (Veenema, 2018b; Veenema, 2018c). 

Additional Disaster Planning and Disaster/Mass Casualty Response Resources

The CDC provides electronic access to evidence-based isolation guidelines.  The CDC app is free of charge and can be downloaded to a smartphone, tablet or PC. Appendix A of the Isolations Guidelines document, Types and Duration of Precautions Required for Selected Infections and Conditions, provides a comprehensive alphabetized list of diseases or conditions, the type and duration of isolation precautions, and a comment column containing additional information relevant to the use of precautions to assist in decision-making (Siegel et al., 2019, p. 96-116).  Table 3 of the Isolations Guidelines document, Infection Control Considerations for High Priority Diseases that May Result from Bioterrorist Attacks, contains information on the incubation period, modes of transmission, clinical features, infectivity, and recommended isolation precautions (Siegel et al., 2019, p. 120-123).

FEMA’s Emergency Management Institute hosts a National Training and Education Division website which contains an online course catalog of emergency preparedness and disaster response courses which are available at no charge (FEMA, 2018b). 

The UNDRR provides a global perspective on evidence-based best practices for disaster risk reduction (UNDRR, 2019).

References

Atisi-Selmi, A., Egawa, S., Sasaki, H., Wannous, C., & Murray, V. (2015). The Sendai framework for disaster risk reduction: Renewing the global commitment to people’s resilience, health, and well-being. International Journal of Disaster Risk Science, 6 (2), 164-176. doi: 10.1007/S13753-015-0050-9

American Nurses Association. (2017). Who will be there? Ethics, the law, and a nurse’s duty to respond in a disaster, Issues Brief. Retrieved from https://www.nursingworld.org/~4ad845/globalassets/docs/ana/who-will-be-there_disaster-preparedness_2017.pdf

Cipriano, P. F. (2018). Responding to disasters: A conversation with Rear Admiral Sylvia Trent-Adams. American Nurse Today, 13 (2), 22.

The Centers for Disease Control and Prevention. (2018). Emergency Responders: Tips for Taking Care of Yourself. Retrieved from https://www.fema.gov/media-library-data/1533052524696-b5137201a4614ade5e0129ef01cbf661/strat_plan.pdfhttps://emergency.cdc.gov/coping/responders.asp

Davis, E. A., Hansen, R., Peek, L., Phillips, B. & Tuneburg, S. (2018). Identifying and accommodating high-risk, high-vulnerability populations in disasters. In Veenema, T. G. (Ed.) Disaster nursing and emergency preparedness for chemical, biological. and other hazards (4th ed., pp 114-138). New York, NY: Springer Publishing

Davison, J. A. (2019). The “cost” of hurricane Florence -- A nurse practitioner’s perspective. Tar Heel Nurse, 81(1), 8–20.

Federal Emergency Management Agency. (2016). National Response Framework (3rd ed.). Information Sheet. Retrieved from http://www,fema.gov//national-response-framework

Federal Emergency Management Agency. (2018a). Creating your family emergency communication plan. Retrieved from
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Federal Emergency Management Agency. (2018b). Emergency Management Institute: National Training and Education Division. Retrieved from https://training.fema.gov/

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McSweeney-Feld, M. H., & Lane, S. J. (2019). Disaster preparedness in turbulent times: lessons in building a culture of readiness. Aging Today, p. 9.

Markinson, D. & Losinski, S. (2019). Hospital and emergency department preparedness. In Veenema, T. G. (Ed.) Disaster nursing and emergency preparedness for chemical, biological. and other hazards (4th ed., pp 51-80). New York, NY: Springer Publishing.

Nash, T. J. (2015). Unveiling the truth about nurses’ personal preparedness for disaster response: A pilot study. MEDSURG Nursing, 24(6), 425–431.

Rebmann, T. (2014). Emergency Preparedness. Grota P. (Ed.). APIC Text Online. Arlington, VA: Association for Practitioners in Infection Control and Epidemiology. Retrieved from  http://text.apic.org/toc/community-based-infection-prevention-practices/emergency-management

Sathasivan, K. (2019). Care for the caregiver: Helping nurses before, during and after disaster situations. Tar Heel Nurse, 81(1), 9.

Siegel, J. D., Rhinehart E., Jackson M., Chiarello, L. & the Healthcare Infection Control Practices Advisory Committee. (updated July 2019). 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved from https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html

Sledge, D., & Thomas, H. F. (2019). From disaster response to community recovery: Nongovernmental entities, government, and public health. American Journal of Public Health, 109 (3), 437–444.

Trossman, S. (2017). Disasters abound: Nurses respond to the needs of patients and their communities. American Nurse Today, 12(11), 38–41. 

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United Nations Office for Disaster Risk Reduction. (2019). Retrieved from https//www.unisdr.org

U. S. Department of Health and Human Services Chemical Hazards Emergency Management. (2019). START adult triage algorithm: Text version. Retrieved from https://chemm.nlm.nih.gov/startadult.htm

Veenema, T. G., Lavin, R. P., Griffin, A., Gable, A. R., Couig, M. P., & Dobalain, A. (2017). A call to action: The case for advancing disaster nursing education in the United States. Journal of Nursing Scholarship, 49 (6), 1-9.

Veenema, T. G. (2018a). Creating a personal disaster plan. In Veenema, T. G. (Ed.) Disaster nursing and emergency preparedness for chemical, biological. and other hazards (4th ed., pp. 693-696). New York, NY: Springer Publishing.

Veenema, T. G. (2018b). Creating healthy, sustainable communities after disasters. In Veenema, T. G. (Ed.) Disaster nursing and emergency preparedness for chemical, biological. and other hazards (4th ed., pp 671-674). New York, NY: Springer Publishing.

Veenema, T. G. (2018c). Essentials of disaster planning. In Veenema, T. G. (Ed.) Disaster nursing and emergency preparedness for chemical, biological. and other hazards (4th ed., pp. 2-22). New York, NY: Springer Publishing.