18. New Era in Public Health: Nursing on the Front Line

Historically, Red Cross nurses have provided assistance during times of disaster and conflict, beginning with the 1888 yellow fever epidemic. The nation relied on the home nursing program of the Red Cross during the critical shortages of nurses during World War II. During this period, Red Cross nurses taught the lay public how to give care in the home, including infant care and home care to sick family members.

Today more than 40,000 nurses continue to be involved in paid and volunteer capacities at all levels and in all service areas throughout the American Red Cross. Nurses are involved in all areas of Health and Safety Services. Because of their training, education, and experience they have skills applicable to a broad range of activities and roles within the Health and Safety Service

Existing CDC communicable disease regulations are outdated; they have been updated very little in the last 25 years. In 2003, building on the SARS experience, the CDC began increasing the number of quarantine stations and enhanced the training and response capacity of all staff. The “CDC is committed to protecting health by preventing the introduction of communicable diseases into the United States,” said CDC Director Dr. Julie Gerberding, in November 2005.

Ready or not, the United States government expects nurses to be on the front line of defense and treatment in the event of a bioterrorism attack or natural pandemic. Increasing awareness and knowledge of possible bioterrorism agents and attacks will allow for appropriate and effective responses. Hospitals and clinics will have the first opportunity to recognize and initiate a response to a bioterrorism-related or natural outbreak. Therefore, overall disaster plans must address the issue.

Public Health

• February 26, 1993 explosions at New York’s World Trade Center
• April 19, 1995 bombing at the Murrah Federal Building in Oklahoma City
• September 11, 2001 attacks on the World Trade Center, New York
• Anthrax cases that followed 9-11

As we have seen, these traumatic public events and the realistic possibility of future terror attacks ushered in a new era in public health, safety, and health care in the United States. Any type of catastrophe can interrupt essential services, such as health care, electricity, water, sewage/garbage removal, transportation, food distribution and communications. Recently, Hurricane Katrina clearly demonstrated that health, social, and economic networks of local communities continue to suffer long after the initial impact of the event.

Driven by the knowledge and the ability to act during a calamity (be it intentionally created or naturally occurring), nurses are first responders and will be sought after for information as well as clinical skills. The need is to be familiar with local disaster plans, understand the role, and know how to communicate with patients, staff, and government agencies. There appears to be an urgent need to prepare for chemical, biological, radiological, nuclear, or explosive emergencies. It almost does not matter what the cause of disruption is; nursing systems must be in place.

It is important that nurses know about signs and clusters of events that may indicate that biological warfare or a pandemic is a possibility. Immediate reporting and implementation of a disaster preparedness and response plan should be considered if the following occur:

• High disease rates among exposed individuals
• Occurrence of a disease that is unusual in a given geographic area
• A naturally vector-borne disease occurring in an area that lacks the appropriate vectors for normal transmission
• More than one epidemic occurring at the same time
• Suspicious activity or discovery of a potential delivery system such as a spray device
• Higher morbidity and mortality than normally expected for a disease
• A rapidly increasing disease incidence (hours or days) in a normally healthy population
• An epidemic curve rising and falling in a short period of time
• Unusual increase in people with fever or respiratory symptoms seeking treatment
• An endemic disease emerging quickly at an unusual time
• Lower attack rates among people who had been indoors compared to those outdoors
• Clusters of patients arriving from a single locale
• Large numbers of rapidly fatal cases
• Any patient presenting with an uncommon disease such as pulmonary anthrax, tularemia or plague

The Four R’s for Nurses as Adopted by Many Organizations

It is of paramount importance to understand the nursing role in an emergency. Disaster response activities can be grouped according to Four Rs: recognize, respond, report, responsibility.

• Recognize that a potential event may be occurring. Know the routes of exposure, their epidemiology, and the signs and symptoms with which they are associated.
  
  
• Respond appropriately to the acute-care needs of your patients in health emergencies. Be familiar with current treatments and their contraindications, as well as the principles of isolation.
  
  
• Report potential events to the appropriate local, state, and federal authorities. The link between medical care and public health is crucial. Knowing how to contact the local health department is a first step. Public health surveillance varies by municipality
  
  
• Responsibility refers to one’s duty to address needs of work and family by developing personal disaster plans.

Children Are Vulnerable

Children are particularly vulnerable to aerosolized biological attacks and may show signs and symptoms sooner than the general population. Therefore, proactive and comprehensive training of school nurses in disease surveillance, emergency preparedness, response, and reporting plus coordination with broader community resources could provide for early detection. A well-executed response possibly will dramatically minimize the number of victims and maybe slow the spread contagious illness.

The School Nurse in Bio-terror or Pandemics

Nurses would most likely be designated and recognized as first responders in mass casualty emergencies, including those resulting from bioterrorists. Children could be disproportionately affected by such events; therefore local emergency planning committees need to include school nurses when developing disaster plans.

School nurses are the only professional health care providers in most schools. Some children spend up to 10 hours in school each day. Students, teachers, and staff work in close proximity to other people, increasing the opportunity of spreading airborne and droplet diseases. School nurses have easier access to large populations of people than most health professionals and are, therefore, in positions to monitor unusual signs, recognize patterns of symptom presentation, act to protect against the spread of communicable diseases, and provide immediate treatment or decontamination for members of the school community.

Additionally, school nurses frequently assess students and staff before students and staff consider themselves ill enough to seek other professional health assistance. School nurses are, therefore, potentially in a position to provide earlier detection of a significant event, thus improving patient outcomes and decreasing the spread of disease.

School nurses with appropriate training/support are a natural choice to augment public health staff in these mass distribution clinics in response to a bioterrorist event or natural outbreak. Therefore, schools that employ adequate school nurse coverage and medical disaster planning principles are potential critical resources in both small-scale events and widespread community disasters.

In the event of a biological or chemical attack on the United States, school nurses would be among the first health care professionals to recognize the event and respond. School nurses can serve as public health sentinels in such events. School nurses should be trained in protection, detection, and treatment of victims; given the authority to command and manage. Training in coordination of response with other community providers would be essential.

Here are some of the many skills and roles that school nurses could bring to emergency preparedness:

1. Knowledge of exposure patterns related to school attendance and activities.
   
   
2. Ability to participate in surveillance and disease pattern recognition/communication
   
   
3. Ability to assess potential emergency risks.
   
   
4. Ability to assess the need for and to institute isolation procedures per state public health law and/ or CDC guidelines.
   
   
5. Ability to assess the adequacy of emergency trainings and practice activities.
   
   
6. Position on the front line when an emergency occurs and involvement in the response to all serious adverse events that threaten the health, safety, or well being of a school and its community.
   
   
7. Possession of detailed knowledge of the needs of children with special health care needs and the ability to plan for these students needs in emergency situations.
   
   
8. Ability to assist in the short-term and long-term recovery phase after a traumatic event. As a “gate keeper”, a school nurse is often first, and perhaps the only health care professional to assess, treat, and possibly refer the child to other health care facilities.