Disasters and infectious disease outbreaks over the last several years have demonstrated the importance of emergency preparedness for large-scale events affecting many people. The ability to respond effectively to events producing a massive influx of patients that disrupt daily operations requires surge capacity. Key components of surge capacity include the four S’s: ‘staff,’ ‘stuff,’ ‘structure,’ and ‘systems.’ As experts in planning and coordinating patient care, nurses have a crucial role to play in disaster planning. Nurses must become familiar with the concept of surge capacity and understand both how it relates to the health and safety of communities and how it is applicable to their nursing practice. This article explores the concept of surge capacity and describes how surge capacity can be useful in various aspects of emergency preparedness planning.
Key Words: disaster, disaster planning, disaster preparedness, emergency preparedness, nursing role in surge capacity, surge capacity
Anthrax. Severe acute respiratory distress syndrome (SARS). Katrina. Ike. Pandemic influenza. All these words highlight the importance of local, regional, and national emergency planning. Since 2001, efforts at emergency planning have increased in the United States (U.S.), and various organizations have made recommendations for emergency preparedness and emergency management plans. For example, The Joint Commission (TJC, 2003) has made emergency planning, based on hazard vulnerability analysis, a requirement. The U.S. Department of Health and Human Services, (U.S DHHS, 2008), the Agency for Healthcare Research and Quality (AHRQ, 2005), and the Centers for Disease Control and Prevention (CDC, 2008) have begun to emphasize emergency preparedness in their research agendas. The Department of Homeland Security (DHS, 2008) has funded initiatives designed to improve emergency preparedness.
A critical component of the ability to respond to large-scale disasters is surge capacity. Effective emergency preparedness in the healthcare arena requires planning for large-scale events that affect many people. These events may include chemical, biological, radiological, or natural disasters. The aftermath of Hurricane Katrina provides a vivid example of a large-scale, natural-disaster event. Infectious disease outbreaks, such as severe acute respiratory distress syndrome or pandemic avian flu, provide yet other examples of potentially, large-scale events. A critical component of the ability to respond to large-scale disasters is surge capacity.
The study of surge capacity is a relatively recent science, studied most commonly in the fields of military and emergency medicine and public health. Few nurses outside of these arenas are familiar with the concept; and even within these arenas, the definition of surge capacity remains elusive. As surge capacity becomes a greater focus of discussion and research in the realm of disaster planning and emergency preparedness, it is crucial that nurses understand the concept of surge capacity and its relevance to their practice. One way to achieve this increased awareness is through the use of concept analysis.
Concept analysis is a process that examines the basic elements of a concept, describes the meaning and use of the word or terms expressing the concept, and explores how the concept’s terminology is similar to, or different from, related words. Concept analysis assists in clarifying the meaning of concepts so that subsequent terminology usage is consistent. The process leads to an operational definition of a concept, which allows questions to be more clearly defined for study and more readily tested (Walker & Avant, 2005). The purpose of the concept analysis presented in this article is to help nurses grasp the meaning and implications of surge capacity so as to improve their clinical practice and facilitate research in this area.
As surge capacity becomes a greater focus of discussion and research in the realm of disaster planning and emergency preparedness, it is crucial that nurses understand the concept...and its relevance to their practice. Developing standardized terminology and establishing clear questions regarding the concept of surge capacity are essential for effective disaster planning and preparedness. Because surge capacity has not yet been clearly defined, its study and measurement is challenging. Currently it is difficult for a healthcare organization or region to know what it must do to achieve surge capacity for large-scale events or how plans will need to change based on the type of event, be it a widespread infectious disease, natural disaster, or radiologic event. Optimal clinical outcomes require answers to such questions. To ensure optimal outcomes in disaster preparedness, surge capacity must be operationalized effectively across the full spectrum of healthcare (Barbisch & Koenig, 2006). Nurses can play a crucial role in this effort by developing a clear understanding of the concept that can lead both to expansion of nursing knowledge through research and improved clinical outcomes through more effective disaster planning based on evidence.
Walker and Avant (2005, p. 65) have described one of the most frequently utilized nursing frameworks for concept analysis. This framework provides guidelines that are valuable because they serve as prompts to consider a concept from multiple perspectives.
The procedures in their framework include the following:
- Selection of a concept
- Determination of the aims or purposes of the analysis
- Identification of all uses of the concept
- Determination of defining attributes
- Identification of a model case
- Identification of borderline, related, contrary, invented, and illegitimate cases
- Identification of antecedents and consequences
- Definition of empirical referents
Walker and Avant’s framework guides the concept analysis described in this article. In place of identifying a single model case, as proposed in the Walker and Avant framework, the author will discuss implications of surge capacity for disaster planning by healthcare organizations and nursing administrators.
Review of Literature
No single definition or measurement standard for surge capacity exists in the realm of healthcare or disaster planning. A keyword search for “surge capacity” using PubMed, CINAHL, SOCIndex, and PsychInfo revealed 225 articles that addressed the topic. An additional search was performed using the reference lists from articles located in the surge capacity search. Most articles focusing on surge capacity are located in emergency medicine journals. The few nursing articles that have addressed surge capacity, as an element of disaster preparedness, were located in journals focusing on emergency nursing (Chapman & Arbon, 2008; Jagim, 2007) and public health nursing (Jakeway, LaRosa, Cary, & Schoenfisch, 2008; Kuntz, Frable, Qureshi, & Strong, 2008).
It is helpful to start the exploration of surge capacity with a look at common meanings of the terms. Webster’s Online Dictionary (2009b) defines surge as “a sudden forceful flow” or “a sudden or abrupt strong increase” and defines capacity (2009a) as the “ability to perform or produce” or “the maximum production possible.”
No single definition or measurement standard for surge capacity exists in the realm of healthcare or disaster planning. One general description of surge capacity is the “ability to manage a sudden, unexpected increase in patient volume that would otherwise severely challenge or exceed the current capacity of the healthcare system” (Hick et al. 2004, p. 254). The Joint Commission (2008) has defined surge capacity as “the ability to expand care capabilities in response to sudden or more prolonged demand” (p.19). Health Resources and Services Administration (HRSA) has attempted to describe surge capacity in terms of numeric benchmarks; it has defined regional surge capacity as the ability to triage, treat, or reach a disposition of 500 cases per million for infectious diseases, and 50 cases per million for each of the following incidents: chemical toxicity, burns or trauma, and radiation (HRSA in Schultz & Koenig, 2006). The Task Force on Mass Casualty Critical Care suggested that hospitals planning to provide emergency mass critical care (EMCC) for a total critically ill patient census be able to triple their usual Intensive Care Unit (ICU) census for as long as 10 days without external support (Rubinson et al., 2008b).
Surge capacity has been studied more thoroughly in regard to emergency departments (ED) and out-of-hospital response than for inpatient hospital care. This gap is of concern because “the ability of hospitals to accommodate new inpatients is crucial for the maintenance of ED functions in a mass-casualty incident” (Kanter & Moran, 2007, p. 314). Until more published data on the balance between projected disaster needs and existing hospital resources are available, planning will be difficult (Kanter & Moran). This concern has begun to be addressed with the formation of a Task Force on Mass Casualty Critical Care to develop a framework for delivery of emergency mass-critical care. The Task Force is a broad-based group made up of healthcare experts from a variety of fields, such as critical care, emergency medicine, disaster medicine, and public health, and from a variety of organizations, including the Department of Health and Human Services, Department of Defense (DoD), CDC, and DHS.
Hospitals of all sizes and in all settings face challenges...to meet surge demands. Large hospitals... typically operate “at or near capacity...". Smaller hospitals...are faced with limited availability of resources and outside support... Hospitals of all sizes and in all settings face challenges to their ability to meet surge demands. Large hospitals, particularly those who anchor community safety nets, typically operate “at or near capacity, so their ability to serve a large influx of critical patients is limited” (Katz, Staiti, & McKenzie, 2006, p. 953). Smaller hospitals, particularly those in rural areas, are faced with limited availability of resources and outside support, including smaller or nonexistent local public health departments, limited communication technology, reliance on volunteers, poorly equipped medical transport units, and greater distances from other potential lifesaving or supportive resources (Manley et al., 2006, p. 80).
Surge capacity is addressed in several state-of-the-science or conceptual articles that have been published primarily in emergency medicine journals. Barbisch and Koenig (2006) have described essential elements of surge capacity. Bonnett et al. (2007) have proposed a conceptual framework to increase understanding of surge capacity. Phillips (2006) reported on research supported by AHRQ. Experts at a medical conference on surge capacity met in a breakout session to identify priority research topics; the results of this session were published by Rothman, Hsu, Kahn, and Kelen (2006). The Task Force on Mass Casualty Critical Care has produced several reports addressing current capabilities for care of the critically ill during a disaster and factors affecting these capabilities (Christian, Devereaux, Dichter, Gerling, & Rubinson, 2008; Rubinson et al., 2008a; Rubinson et al., 2008b). In a conceptual analysis of emergency preparedness, Slepski (2005) advocated the need for “development of systems of metrics for measuring capacity and performance” (p. 427).
Components of Surge Capacity
...general agreement does exist on [surge capacity] key components, which are referred to as...‘staff,” “stuff,” “structure,” and “systems.”...Systems receive the least attention of all the “S’s”...Although no single definition or measurement standard for surge capacity exists, general agreement does exist on its key components, which are referred to as the “4 S’s” of ‘staff,” “stuff,” “structure,” and “systems.” Staff refers to personnel, stuff consists of supplies and equipment, structure refers to facilities, and systems include integrated management policies and processes (Barbisch & Koenig, 2006; Phillips, 2006; Schultz & Koenig, 2006). These key components may be described as “defining attributes,” which are the cluster of attributes most frequently connected with the concept (Walker & Avant, 2005).
In the world of healthcare, staff refers to clinical personnel, such as nurses, physicians, pharmacists, respiratory therapists, and technicians. Staff also refers to a host of other personnel necessary for the functioning of a given healthcare facility or entity, such as clerical support personnel, security specialists, and physical plant specialists.
Healthcare stuff includes durable equipment, such as cardiac monitors, defibrillators, intravenous (IV) pumps, ventilators, blood glucose monitors, wheelchairs, and beds. Stuff also includes consumable supplies, such as medications, oxygen, sterile dressings, intravenous fluids, IV catheters, syringes, sutures, and personal protective equipment.
Hospitals are the first structures that come to mind in healthcare, although extended care facilities, community health centers, laboratories, and public health departments also comprise the structure component of surge capacity. Hospitals are the first structures that come to mind in healthcare, although extended care facilities, community health centers, laboratories, and public health departments also comprise the structure component of surge capacity. A more comprehensive view of structure will also include “buildings of opportunity” that preferably will have capacity to hold more than 1000 people. Such buildings include hotels, convention centers, and gymnasiums (Barbisch & Koenig, 2006, p. 1000).
Systems for healthcare organizations include integrated policies and procedures that link departments within the healthcare facility. Additionally, systems can refer to policies and procedures that can link the healthcare facility with other aspects of healthcare, such as out-of-hospital emergency medical services (EMS), home healthcare, and physician offices. The Joint Commission has recommended cooperation with community organizations to enhance surge capacity in case of a disaster. This would require expanding systems to include cooperative agreements developed with the healthcare organizations and local voluntary organizations active in disaster (VOAD). Systems receive the least attention of all the “S’s” and in fact, this “S” is sometimes left out of the list, leaving “3 S’s” of staff, stuff, and structure.
Indicators of Surge Capacity Need
A “surge generating event” must occur before surge capacity can actually be put to the test...Surge generating events can be contained or population based. Surge generating events can be contained or population based. A “surge generating event” must occur before surge capacity can actually be put to the test. Events, such as disasters or other emergencies, can be described as “antecedents” (Walker & Avant, 2005). Surge generating events can be contained or population based. A contained event has a distinct geographic focus, even if the focus is very large. The incident site is integral to a contained event. A population-based event is not geographically defined and can spread infectiously.
The type of surge-generating event will play a major role in how surge capacity will be developed. Depending on the need, surge capacity may be developed from several perspectives, including intrinsic, extrinsic, or evacuee-related. Intrinsic surge capacity considers the local resources and strategies that healthcare facilities and communities near a disaster can implement to expand operations (Bonnett et al., 2007). Extrinsic surge capacity may employ strategies that include bringing outside assistance into an affected area and evacuation of survivors to unaffected areas (Bonnett et al.). Evacuee surge capacity is developed from the perspective of an unaffected area. Planning from this perspective considers the community’s capacity for a variety of resources including transportation, shelter, food, and healthcare. The goal of planning from this perspective is to distribute evacuees in such a way that relatively normal operations can be maintained (Bonnett et al.). This approach may be critical for prevention of a shift to EMCC.
What Surge Capacity Is Not
Surge capacity is not a single component; it is not static; and it is not standard daily operations. It is sometimes easier to describe what surge capacity is not, rather than to define what it is. Surge capacity is not a single component; it is not static; and it is not standard daily operations. When we discuss these examples of what surge capacity is not, we are often describing borderline cases or contrary cases. A borderline case is an instance containing some, but not all, of the key components or antecedents of surge capacity (Walker & Avant, 2005). A contrary case is an example that truly does not illustrate the concept of surge capacity (Walker & Avant). Borderline cases, the dynamic nature of surge capacity, and contrary cases will be discussed below.
Borderline cases of surge capacity result from consideration of fewer than each of the defining attributes of surge capacity. Often borderline cases result from consideration of only one component of surge capacity. It is important to remember that surge capacity is not simply one component. In the hospital setting, surge capacity has often been measured through the use of inpatient occupancy rates and the number of empty beds that would be immediately available in an emergency (DeLia, 2006; Taylor, 2003). Although hospital-bed statistics are readily available and easy to calculate, they do not take day-to-day census variations or within-year bed availability changes into consideration. Failure to consider these variations can lead to an inaccurate picture of actual day-to-day availability of maintained beds. Furthermore, this measurement is too simplistic because it is limited to one aspect of surge capacity. It does not take into account the healthcare staff that would be required to provide care for patients being placed in the beds; nor does it take into account availability of supplies such as medications, oxygen tubing, and intravenous catheters required for the care of the patients.
Surge capacity...has multiple components and each...can vary in different ways at different times. As the demands...change, so does an organization’s surge capacity. Surge capacity is not static. Rather it has multiple components and each of these components can vary in different ways at different times. As the demands on the individual components change, so does an organization’s surge capacity. For example, a hospital that typically operates at full census and treats 180 people in its emergency department each day may see 150 additional people following a train derailment that has caused a toxic-gas release. At least 100 people may need to be admitted due to respiratory complications. They all require cardiac monitoring; yet all the telemetry beds in the hospital are full. This hospital may have adequate surge capacity for most disasters, but may not have the capability of handling this very specific disaster. The hospital’s structure and stuff components of surge capacity are altered by the disaster’s unique demands combined with day-to-day patterns.
Surge capacity is not standard daily operations. Some authors (Asplin, Flottemesch, & Gordon, 2006; Jenkins, O’Connor, & Cone, 2006; McCarthy, Aronsky, & Kelen, 2006) refer to “daily surge” when describing spikes in patient volume during routine operations. Other authors (Bonnett et al., 2007) emphasize that if standard op...if standard operations can address the situation, it is not truly surge. To use the same term for both daily operations and disaster operations leads to confusion. erations can address the situation, it is not truly surge. To use the same term for both daily operations and disaster operations leads to confusion. Bonnett et al. point out that “a system is either functioning under normal daily operations or it is not” (p. 300). Rubinson et al, (2008b) make a similar point with respect to critical care, indicating that EMCC is a departure from everyday function and should be used only when the number of critically ill patients exceeds the capability of the usual system.
Furthermore, attention has recently focused on the need to adopt altered standards of care during disaster response (AHRQ, 2005; DoD, 2008). Healthcare personnel responsible for emergency planning are now faced with mandates to find different ways to allocate scarce resources while providing care to an influx of casualties (AHRQ, 2005; DoD, 2008). In such an event, sufficiency of care becomes the expectation; sufficient care is that which is provided to meet individuals’ immediate needs, but not necessarily meet standard care or ideal care needs. When a disaster requires a healthcare system to move beyond the threshold of providing standard care to an environment of sufficient care, surge becomes applicable (Bonnett et al.).
A number of related concepts exist, some of which have been used interchangeably with the term surge capacity. Related cases or concepts are similar to surge capacity but differ in some way (Walker & Avant, 2005).
Emergency preparedness is an example of a related concept. A recently proposed definition of emergency preparedness is “the comprehensive knowledge, skills, abilities, and actions needed to prepare for and respond to threatened, actual, or suspected chemical, biological, radiological, nuclear or explosive incidents, man-made incidents, natural disasters, or other related events” (Slepski, 2005, p. 426). Surge capacity clearly plays a crucial role in emergency preparedness but is not specifically addressed or illustrated by this definition.
Other examples of related concepts include various phrases that include the word surge. They include surge readiness, surge protection, and surge capability. Surge readiness has occasionally been used as a synonym for surge capacity (Taylor, 2003). Surge protection is “the ability to expand the capacity of [the] system to triage or treat more patients in a staff-challenged environment” (Taylor, p. 92). Surge capability is a concept that best describes specialized resources or skills needed to address special needs for specific populations (Bonnett et al., 2007). Examples may include individuals requiring dialysis or ventilatory support.
Proposed Definition of Surge Capacity
Based on the previous analysis, surge capacity may be described in the following manner:
The ability to obtain adequate staff, supplies and equipment, structures and systems to provide sufficient care to meet immediate needs of an influx of patients following a large-scale incident or disaster.
This definition must be further refined based on the type of surge-generating event and on the perspectives from which it is viewed: intrinsic, extrinsic, or evacuee-related. Further exploration into these areas may be helpful in establishing more specific measurements of surge capacity.
Implications for Disaster Planning in the Healthcare System
Healthcare personnel...are now faced with mandates to find different ways to allocate scarce resources while providing care to an influx of casualties...Plans that collect dust on the shelf and are understood by only a few key staff will be of little use in...an actual disaster. For disaster plans to be effective, they must be dynamic as well as common knowledge for staff. Plans that collect dust on the shelf and are understood by only a few key staff will be of little use in the event of an actual disaster. Nurses should make every effort to be thoroughly informed about their organization’s disaster plan and to advocate for disaster drills that include a cross-section of personnel on a variety of shifts.
Nurses who are involved in disaster planning should guard against merely making static resource lists. Whether the lists are of staff, supplies, or additional facilities available for emergency treatment, the tendency is to assume that the staff will respond when called, the supplies will be in place whenever they are needed, and the most desirable building-of-opportunity will be unoccupied. Those assumptions are often wrong, even in small- or moderate-scale disaster events. To avoid being unprepared when disaster strikes, nurses should anticipate the need to plan creatively for the 4 S’s of surge capacity.
Planning for Staff
...shared staffing [and] cross training [may] maximize the number of trained staff available...All nurses should develop a personal disaster plan so as to be part of the solution to staffing needs in a disaster event. In addition to calling in staff members and changing staff schedules, it will be important to seek supplemental staff support from other organizations (Christian et al., 2008). Examples include Emergency Systems for Advance Registration of Volunteer Health Professionals (ESAR VHP), Medical Reserve Corps (MRC), the American Red Cross, public health departments, and/or schools. Additional support may come from faith-based community members and voluntary organizations active in disaster (VOAD) (Cantrill, Bonnett, Hanfling, & Pons, 2007; Hick et al., 2007; Katz et al., 2006; Koenig, 2007). Healthcare facilities may wish to consider shared staffing of specialty staff with other hospitals or healthcare organizations (Rubinson et al., 2008b). Cross training may maximize the number of trained staff available, especially in the event of a large-scale disaster. Nurses should be aware of barriers that may affect the willingness and ability of staff to report for duty following a disaster (Qureshi et al., 2005). Nursing administrators, managers, and team leaders should consider ways to alleviate the barriers to adequate staffing within the organization or partner with other organizations that can help alleviate these barriers (Christian et al., 2008; Qureshi et al., 2005). All nurses should develop a personal disaster plan so as to be part of the solution to staffing needs in a disaster event (Adams, 2009; Phillips & Knebel, 2007).
Planning for Supplies and Equipment (Stuff)
Nursing staff should be prepared to function effectively in situations that require altered standards of care...[and be able to] perform manual blood pressures, take temperatures without electronic thermometers, and administer IV drips via gravity infusion. Nursing staff should be prepared to function effectively in situations that require altered standards of care. Clinical educators should make sure staff can perform manual blood pressures, take temperatures without electronic thermometers, and administer IV drips via gravity infusion. For staff to be able to do so, facilities will need to obtain alternate equipment such as sphygmomanometers, battery-operated thermometers, and micro drip tubing. Staff will also have to consider how to reuse disposable equipment, such as gloves, gowns, and masks (Rubinson et al., 2008a). During a disaster, healthcare personnel will need to allocate beds, ventilators, and other supplies in a manner consistent with the goal of saving the most lives (AHRQ, 2005). Nursing administrators may need to plan for means to supply alternate-care sites with oxygen, point-of-care testing equipment, walkers, wheelchairs, personal protective equipment, and other supplies. It will be important to ensure that a supply chain exists, especially for pharmaceuticals (Cantrill et al., 2007; Christian et al., 2008). Not only will this include establishing alternate sources for medications and potential stockpiling, it may also include retrieving medications from an electronic system, such as a Pyxis system, in the event of a power outage and finding alternate storage sites for controlled substances.
Planning for Structure
Nurses in administrative or managerial roles should consider alternate uses of existing facilities of opportunity that can be adapted into surge hospitals because of their size or proximity to a medical center (Cantrill et al., 2007). Examples include on-site recreational centers, churches, community centers, schools, sports facilities, and hotels. Staff nurses, team leaders, and supervisors need to be aware of patients that can be discharged or moved to other units to free up beds. Managers should be aware of additional in-network facilities such as sub acute units and skilled-nursing facilities (Hick et al., 2004; Phillips, 2006) Administrators should plan to develop partnerships with nearby organizations, such as community centers, hotels, or schools (Cantrill et al., 2007; Hick et al., 2007). It will be important to consider mobile and portable facilities, although experts predict that most alternate-care sites will be facilities of opportunity because of the potential challenges of staffing and/or supplying other alternate-care sites (Cantrill et al., 2007).
Planning for Systems
Effective systems planning will consider internal and external communication processes. When communication systems are disrupted due to power outages, circuit overload, or cellular tower losses, it will be crucial to have alternate plans in place (Cantrill et al., 2007). Nurses need to be familiar with communication plans so that they can communicate effectively with outside entities such as EMS, nursing homes, and public health officials, if necessary. They also need to be familiar with alternate communication devices within the facility, such as two-way radios (International Nursing Coalition for Mass Casualty Education, 2003). Basic questions that must be answered in any disaster include:
- When are standard operations overwhelmed?
- When is it appropriate to alter standards of care?
- When do providers need to strive to provide sufficient care, rather than standard or ideal care?
As these questions are asked and answered, it is vital to know who is responsible for making those decisions and communicating the answers both to the staff and to the community (Hick et al., 2007; Jakeway et al., 2008).
Effective systems planning supports development of decision-making capacity...Disasters do not always occur during the standard business week or day; they often occur during off-shifts, weekends, and holidays. It is crucial for healthcare institutions to be prepared...when the usual personnel to lead a critical event are unavailable. Effective systems planning supports development of decision-making capacity. This includes having effective decision-making processes in place, with multiple staff members prepared and empowered to make key decisions as needed (Hick et al., 2007). Disasters do not always occur during the standard business week or day; they often occur during off-shifts, weekends, and holidays. It is crucial for healthcare institutions to be prepared for events when the usual personnel to lead a critical event are unavailable. Realistic disaster drills should occur in real-time with no warning; they should engage a wide variety of personnel (Bergin & Khosa, 2007). It is essential for disaster drills to occur during off-shifts and on weekends and holidays to fully test the system.
Another element of systems planning is the relationship of the healthcare institution with the surrounding community and region. Mutual-aid relationships may need to be established within the community, the region, and the state (Rubinson et al., 2008b). Nurse leaders and managers should anticipate being involved in negotiations for such relationships. Nurses at all levels of a healthcare organization will play a role in operationalizing the relationships.
Advocating for effective disaster planning that maximizes surge capacity is a logical extension of the nurse’s role as patient advocate. The last several years have shown that emergency preparedness is essential to respond to a variety of hazards. Part of the ability to respond to disasters and other emergencies involves surge capacity. Surge capacity is relevant to the nursing role in a variety of settings, and nurses must become aware of the concept and how it relates to the health and safety of the community. As experts in planning and coordinating patient care, nurses have a crucial role to play in developing effective disaster plans within their organizations. Advocating for effective disaster planning that maximizes surge capacity is a logical extension of the nurse’s role as patient advocate. Nurses should therefore become active in the study of and planning for surge capacity as it becomes a topic of greater discussion and research.
This manuscript was developed as part of a project partially funded through the Alma and Robert D. Moreton Research Award (2007-2008). The author wishes to thank Orpheulia Davis, RN for assistance with the literature search for this manuscript.
Lavonne M. Adams, PhD, RN, CCRN
Lavonne M. Adams, PhD, RN, CCRN, is an Assistant Professor in the Texas Christian University Harris College of Nursing & Health Sciences. She served as the chair of Tarrant County Voluntary Organizations Active in Disaster (VOAD) from 2006-2008, as a Disaster Health Services Volunteer for the American Red Cross since 2005, as the Adventist Community Services Disaster Response (ACS-DR) representative to Tarrant County VOAD since 2004, and a volunteer and trainer for ACS-DR since 2003. Dr. Adams’ clinical background includes critical care and emergency nursing, and she continues as an instructor in BLS and ACLS. She holds a degree with a focus in Leadership from Andrews University (Michigan), an AS in Nursing from the Kettering College of Medical Arts (Ohio), a BSN from Wright State University (Ohio), and an MS in Nursing from Andrews University.
© 2009 OJIN: The Online Journal of Issues in Nursing
Article published March 31, 2009
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