Managing the tension between emergency management policy decisions and residential aged care facility planning in South Australia
Lynette Cusack, Lesley Siegloff, Professor Paul Arbon, Dennis Chamberlain
Emergency planning for vulnerable populations constitutes a major element of community disaster preparedness and is an area where guidance is particularly sparse (Dosa et al., 2008). Following the Victorian bushfires of 2009 and the north Queensland floods 2010-11 a number of national policy decisions were made that directly affected the management of residential aged care facilities (RACFs) in planning for environmental disaster threats. This includes new Australian Government funding requirements for RACFs and adoption by South Australia of a new fire danger rating scale. The scale now includes an extreme weather condition called catastrophic or code-red (Country Fire Service 2010a). Where a catastrophic fire day is predicted for the next day the Bureau of Meteorology will make a public announcement to declare a code-red for the relevant geographic locations. Service providers and community members located in the relevant bushfire prone areas must decide whether or not to evacuate the day before, or morning of, the day declared as code-red.
There is no widely accepted definition of disaster. Most definitions describe it as an ‘overwhelming’ disruption to the community. The World Association for Disaster and Emergency Medicine defines a disaster as:
“an event that interrupts the normal functioning of a community, resulting in the need for external human and/or physical resources to assist in a response beyond that of the normal day-to-day operational capacity for that community” (TFQCDM/WADEM 2002).
Disasters and catastrophic emergencies have the capacity to overwhelm emergency services making it difficult, at least in the short-term, to provide assistance to the broader community (Templeman and Bergin, 2008).
It is necessary for organisations, including RACFs, to have some capability to manage through these situations on their own until other services, including emergency services, can provide additional assistance. The immediate impact of disaster situations on the capacity of agencies external to the RACF, especially emergency services, to provide relief is difficult to assess because each disaster event presents its own unique set of issues related to its environment. A major emphasis in planning for disaster for any organisation is the need to understand the environment, as well as the potential disaster events, and to be relatively self-reliant when the plan is in operation (Templeman and Bergin, 2008).
The aged care sector in Australia is legislated and funded under the Australian Government through the Department for Health and Ageing (Aged Care Act 1997). The state and territory governments’ health departments have no jurisdiction over RACFs in their state or territory. This means that RACFs run the risk of receiving insufficient attention in state government emergency management plans because they are not part of the jurisdiction’s health structure in a formal and legislative sense. The Australian Government may issue a direction to RACFs about emergency and disaster response that is not in keeping with the other government emergency management plans. Therefore there is a potential for friction to develop where two separate jurisdictions are making policy decisions that affect the management of RACFs.
In February 2009, South Australia and Victoria experienced a heatwave unusually excessive in both duration and intensity (Australian Bureau of Meteorology 2011). The extreme weather resulted in the ‘Black Saturday’ fires in Victoria, which claimed 173 lives (Victorian Bushfires Royal Commission 2009). As a consequence of this disaster a Royal Commission was established and a number of important recommendations were made. Two of these had significant consequences for RACFs. They included the changes to the Aged Care Accreditation Standards by the Australian Government for RACFs to establish plans for disaster events such as bushfire and flood, and the change to the Bureau of Meteorology Fire Danger Ratings to include a new category called Catastrophic Fire Day, code-red.
Changes to the Aged Care Accreditation Standards
The Australian Government’s aged care certification and accreditation standards already included a standard requiring RACFs to have evacuation plans in place. The additional requirement to expand evacuation plans to include disaster threats brought to the fore a need for careful planning and review by RACF managers of the implications of the revised standard (Aged Care Standards and Accreditation Agency 2011).
Changes to Community Fire Danger Ratings and Education Department policies
The second change was an extensive re-evaluation of the existing South Australia community bushfire management system which, in light of the Victorian bushfires, was deemed inadequate (Taylor 2010). A revised process model was recommended by the interim report of the Royal Commission (Victorian Bushfires Royal Commission 2009). One of the modifications introduced was an increase of information to the public in the form of more regionally accurate Fire Danger Ratings (Country Fire Service 2010a). A catastrophic day is declared when it is considered:
- that the worst conditions for a bush or grass fire exists, and that
- should a fire start there is a very real likelihood of major loss of life and/or property (Country Fire Service 2010b).
Large fires will not be defendable under these extreme conditions.
On these days community members in bushfire prone areas are advised to implement their bushfire action plans. Where this includes evacuation they need to leave their homes early and relocate to declared safe regional centres. The community is also advised to avoid unnecessary travel on roads in the regions where there is a catastrophic warning (Country Fire Service 2010a).
The catastrophic fire rating recommendation was adopted at the state government level in South Australia and has led to further state policy changes. In November 2009 the Country Fire Service and the Department of Education and Children’s Services in South Australia developed a policy for schools and pre-schools. These institutions would be temporarily closed and school buses cancelled on days of declared catastrophic bushfire weather conditions (Robinson 2009).
An announcement is made by the schools and preschools the day prior to the forecast catastrophic conditions, detailing those subject to closure. This is designed to help families make alternative arrangements for their children’s care. The policy to close schools has the potential to affect the ability of services and businesses in the bushfire risk areas to maintain effective staffing levels on these particular days, as most employees of RACFs are female and, often, carers of school-aged children.
There are essential services, such as hospitals and RACFs, that must be maintained in the community, regardless of the fire risk. Staff availability may be reduced on catastrophic conditions days for many of the semi-rural and rural hospitals and RACFs. School closures may mean staff need to be with their children and prepare their properties. Staffing of these facilities may be more difficult on these high fire risk rating days.
The tensions that these policy changes placed on RACFs were recognised by a number of Chief Executive Officers (CEO) of licensed RACFs in South Australia. One CEO was so concerned with the potential implications of the policy changes that the Flinders University Disaster Research Centre was approached to run disaster management planning sessions for interested managers of RACFs. What ensued was a number of workshops at which RACF managers explored the key issues and analysed their planning needs to develop a disaster management plan.
Issues for Aged Care Service Managers
RACFs in South Australia were not linked into the state government or local government emergency management planning processes, unless they are attached to a hospital service. Local governments are required to have a Bushfire Plan for their council area, but are only able to provide minimal support to RACFs such as advice on local risks. This is due to the separate legislation and funding responsibilities between Australian, state and local governments and a limitation on their available resources and ability to provide support in the event of a disaster.
This lack of connectedness of RACFs to a state’s disaster emergency planning is important because, as identified from the Hurricane Katrina experience, where the RACFs were not part of the broader health service disaster plan they were not recognised as essential services and were not included as a priority area in response and recovery operations. Consequently, unlike hospitals, they did not receive adequate resources (Latika et al. 2007; Dobalian et al. 2010). It is important that RACFs are involved in state and local government disaster planning because it provides both the emergency planners and the RACFs a clear understanding of their level of access to emergency support and supplies.
As RACF managers have not been part of the disaster planning process many were unsure about where to go for advice and assistance to help them meet the new accreditation requirements in disaster response. This was the first time that many of the managers realised that if a disaster event was to happen they were potentially on their own. There are no guarantees that the emergency services would be able to assist them. A number of RACF managers had, up until this time, vested the decision-making for event control with emergency services who they believed would be in a position to respond quickly to their needs.
In the past, some RACF managers had undertaken a hazard analysis of their facility’s geographical location, surrounding environment, building structures, staffing availability and lifelines. However this was with an expectation that emergency support would be quickly available. The hazard analysis was often not linked to the notion that they may have to defend on their own and may be without support for long periods of time.
The unpredictability of disasters makes it difficult for RACF managers to plan for the range of potential impacts and the responses that may be required. Better preparation entails efforts to understand risks and to strengthen the absorbing, buffering and response capacities of the facility, its staff and residents: in so doing, reducing the extent of damage and the effects of that damage on the functioning of the facility. The question the managers grappled with was ‘how much preparation is sufficient?’ when the scope and scale of an event is unpredictable. This challenged RACF managers to think about a business and service provision continuity plan taking into account potential disaster events that may occur given their location and level of risk. In particular how long could they survive without water, electricity, medication and food supplies.
To enable alterations to the RACFs to increase the absorbing, buffering and response capacity, a major issue was to determine the extra financial resources required to meet additional budget requirements. This was of particular concern to the smaller RACFs operated through charitable organisations that do not have ready funds for building alterations identified in the hazard analysis.
In planning for a disaster event the RACF managers reviewed the implications for staffing levels on days declared code-red to determine how many staff may have to remain at home with their children if schools close, or who are unable to travel on the roads to get to work, or have to stay at home to defend their property and livestock. They also considered if extra staff were required during code-red days in case of a bushfire event and the activation of their bushfire plan.
To evacuate or not is the most difficult issue for RACF managers to come to grips with. The ability to evacuate residents and the identification of critical decision points in an evacuation of the facility is the issue that managers and staff of the facility discussed the most, because there is no ready-made solution. Managers expressed concern about their ability to make an informed assessment of the risk(s) in the planning and preparation phase, and on the day of an emergency. This risk assessment depends on a complex set of issues such as their proximity to hazards and the risk of potential disaster events, the structure of the facility to withstand the event, type and complexity of resident dependence/needs, staff availability and training, evacuation options and transport access, and the availability of suitable accommodation for those evacuated from the area.
Another aspect that managers explored was the situation that may arise during an event where the RACF becomes the sheltering point for people from the local community as well as their own staff with their families. These discussions highlighted the importance of instigating collaborative arrangements and establishing organisational life-lines with other key services in the local community. The time required to safely evacuate residents without causing harm to very frail elderly residents can take many hours for even the smallest of facilities. Therefore the ability to ‘invacuate’ or shelter in place and protect residents, staff and others in the facility during periods of intense smoke and heat requires support either during or immediately after the fire front has passed. This requires inter-agency awareness and collaboration and appropriate notification systems to ensure that already overwhelmed emergency services can and do respond in a timely manner.
These were the main issues that RACF managers grappled with during the disaster planning workshops. None of these issues have straightforward solutions, especially in the context of facilities located in areas where they are adjacent to identified hazards and are at risk of an event such as a bushfire, flood or cyclone.
Since the disaster workshops a number of RACF managers and their professional body, the Aged and Community Services (South Australia and Northern Territory), lobbied the state government for inclusion in state disaster planning. A working-party was established to undertake a bushfire risk assessment of over 40 RACFs across South Australia funded by the South Australian Department of Health. These RACFs have been provided with a report and defensibility rating of their infrastructure.
This paper discusses how the changes to policy regarding emergency management planning made by one jurisdiction (a state government) can impact on RACFs, licensed by another jurisdiction, the Australian Government. The policy and operational decisions made at the Australian Government level have been made without fully examining the practical implications, particularly for RACF managers. While many of the facilities on which these decisions impact understand the rationale for such decisions, it is argued that these decisions have serious implications for services and residents. Privately-operated RACFs have not historically been involved in any state or local government emergency management planning. The whole concept of risk assessment, preparation and planning to increase the absorbing, buffering and response capacity of their facilities, against extreme weather events, has become, for some, an overwhelming and resource intensive task.
Aged Care Act 1997 (Commonwealth) Australia.
Aged Care Standards and Accreditation Agency. Retrieved 7 November 2011 http://www.accreditation.org.au/site/uploads/30985_AgedCare_ASENGLISHVI_3.pdf.
Australian Bureau of Meteorology. Retrieved 12 October 2011. http://www.bom.gov.au/climate/.
Country Fire Service 2010a. Fire Danger Ratings. October Fact sheet 28. Government of South Australia. Adelaide.
Country Fire Service 2010b. Changes to the calculation of Fire Danger Ratings. October Fact Sheet 41., Government of South Australia. Adelaide.
Department of Health and Ageing. Retrieved 8 November 2011, Aged Care Approval Rounds - Residential aged care places, zero real interest loan and/or capital grant Page 82 Question B 14.2 http://www.health.gov.au/internet/main/publishing.nsf/Content/ageing-acar/$file/Section05.pdf.
Dobalian, A., Claver, M. and Fickel, J., 2010. Hurricanes Katrina and Rita and the Department of Veterans Affairs: A Conceptual Model for Understanding the Evacuation of Nursing Homes. Gerentology. Online March 24: pp. 1-8.
Dosa, D., Hyer, K., Brown, L.M., Artenstein, A.W., Polivka-West, L. and Mor, V., 2008. The controversy inherent in managing frail nursing home residents during complex hurricane emergencies. Journal of the American Medical Directors Association 9(8): pp. 599-604.
Hyer, K., Polivka-West, L., and Brown-Winter, L.M., 2007-2008. Nursing Homes and Assisted Living Facilities: Planning and Decision Making for Sheltering in Place or Evacuation. Generations 31(4): pp. 29-33.
Laditka, S., Laditka, J.N., Xirasagar, S., Cornman, C.B., Davis, C.B., and Richter, J.V.E., 2007. Protecting nursing home residents during emergencies or disasters: An exploratory study from South Carolina. Prehospital and Disaster Medicine 22(1): pp. 42-48.
Robinson, C., 2009. Bushfire Risk Management Strategy for 2009/10: Prepare Phase - School and Preschool Bushfire Closure Policy. Department of Education and Children Services. Adelaide, Government of South Australia.
Taylor, M.A.P.F., and Sally, K., 2010. A review of planning and operational models used for emergency evacuation situations in Australia. Procedia Engineering;3: pp 3-14.
TFQCDM/WADEM 2002: Health Disaster Management: Guidelines for Evaluation and Research in the “Utstein Style.” Glossary of terms. Prehospital Disaster Medicine; 17 (Suppl 3): pp. 144–167.
Templeman, D., and Bergin, A., 2008. Taking a punch: building a more resilient Australia. Strategic Insights, Australian Strategic Policy Institute.
Victorian Bushfires Royal Commission, 2009. Interim report July 2009 of the Victorian Bushfires Royal Commission. Melbourne.
About the authors
Lynette Cusack is a Post Doctoral Research Fellow (Population Health) at the Faculty of Health Sciences Flinders University, South Australia. She is on the Board of the Disaster Research Centre, Flinders University. Her research focuses on issues for vulnerable populations in a disaster.
Lesley Siegloff is an Associate Dean (Practice Development), Senior Lecturer Nursing/Aged Care in the Faculty of Health Sciences, Flinders University, South Australia. Her research is in practice development and leadership in aged care and rural health services.
Professor Paul Arbon is Chair of Nursing (Population Health), Dean of the School of Nursing and Midwifery and Director of the Disaster Research Centre, Flinders University. Paul is the Director of the Torrens Resilience Institute, an Association of four Adelaide universities. Current research is focused on community capacity building and resilience and includes the study of triage decision-making, mass gatherings and the role of nurses in responding to disaster.
Dennis Chamberlain is the Chief Executive Officer James Brown Memorial Trust based at Belair, South Australia. He is also on the Board of the Aged and Community Services (SA and NT) Inc.