Maria Claver, PhD, MSW Research Health Scientist Veterans Health Administration Emergency Management Evaluation Center
California State University, Fullerton Department of Human Services P.O. Box 34080 Fullerton, CA 92834-9480
In addition to its primary mission to provide health services for veterans, the Department of Veterans Affairs (VA) is responsible for assisting federal agencies and the general public during emergencies as directed by the 1982 VA/Department of Defense Health Resources Sharing and Emergency Operation Act (Pub. L. 97-174). Given its nationwide presence, VA must respond to the range of emergencies and disasters through participation in the mitigation, preparedness, response, and recovery stages of emergency management. It does so, in part, through collaboration with other governmental, non-profit, and for profit agencies.
Collaboration requires effective communication through information dissemination. Existing research outside of VA does not adequately address the needs of those in disasters or VA’s activities in assisting its partners. Information about VA and emergency management is most often found in VA internal “after action reports” and is not widely disseminated. There is an urgent need for evidence-based research related to disaster and emergency response processes that VA is likely to engage in. This review thus aimed to explore and summarize the current scientific literature about VA and emergency management and make suggestions for future research.
The first step included searching for relevant emergency management peer-reviewed articles published between 1982 and 2012. RAND Corporation librarians used disaster-related search terms using relevant academic databases (see Table 1) to provide the research team with a list of articles (n=877) that met initial search criteria (i.e. contained search terms mentioned above in the title, keywords, or abstract). Of the 877 articles, 798 were rejected at title review as clearly irrelevant to the project or were excluded as they were not published in peer-reviewed journals. This left 79 peer-reviewed articles that were then reviewed using the following inclusion criteria: 1) the article discussed emergency management, and 2) the article discussed services directly provided by VA, services for which VA contracted from outside entities, or veterans served by VA. Thirty-nine articles met the criteria. The reference lists for these articles were then reviewed for possible inclusion; all but 5 articles were rejected at title review. Of the 5, only 2 met the full inclusion criteria. Thus, 41 total articles were included in the final review for meeting criteria (Figure 1).
All of the articles were then fully reviewed using a data abstraction instrument designed for this study and reviewed by the VA/UCLA/RAND Southern California Evidence-Based Practice Center (Figure 2). The data abstraction instrument categories were compiled from literature reviews, pilot testing of the instrument, and input from experts in emergency management research and practice. The categories on the data abstraction instrument reviewed in the current study included: 1. Study design (e.g., experimental including randomized groups and a control group, quasi-experimental including comparing different groups under different conditions such as time periods or regions, or pre-experimental including examination of one group over time, retrospective reporting, data tracking, program evaluation or descriptive case studies); 2. Methodology (i.e., qualitative, quantitative, mixed); and 3. Role of VA in emergency management (i.e. mitigation/prevention, preparedness, response, recovery). Two members of the research team independently reviewed the articles and compared data coded on the data abstraction instrument. In cases where coding diverged, the team obtained reliability by reaching consensus about the code or via input from a third team member. Finally, the articles were reviewed using content analysis techniques
The study design of the final group of articles was experimental (n=0), quasi-experimental (n=12) or pre-experimental (n=29). Methodologies included qualitative (n=21), quantitative (n=19), and mixed (n=1). The role of VA in the emergency management phases included mitigation/prevention (n=5), preparedness (n=2), response (n=8), or recovery (n=14). Several articles (n= 12) addressed more than one emergency management role, including two articles that addressed all four roles.
Five topic categories emerged from the review: Effects of disaster on mental health status and services use, effects of disaster on general health services use, patient tracking, evacuation, and disaster planning/preparation.
Thirteen articles relate to the effects of disaster on mental health, including service use and status. Among studies that explored mental healthcare use for PTSD symptoms
Regarding mental health functioning, veterans treated in PTSD clinics experienced fewer symptoms at admission after 9/11 than veterans admitted before 9/11, contrary to expectations
In addition to examining PTSD, several studies considered general mental health issues. Following 9/11, there were increases in unscheduled clinic visits by veterans for symptoms of anxiety and depression
Eight studies address general health services use affected by disaster. From the provider’s perspective, it is challenging to provide continuity of care because of several barriers including limited or compromised communication infrastructure
Despite challenges and uncertainty, VA facilities, mobile clinics, and a VA Disaster Application Center (DAC) successfully served veterans and non-veterans alike in the first days following a disaster. Mobile clinics were effective because veterans favored receiving medical care in their communities, but the availability of care through mobile clinics presented the challenge of treating non-routine populations, such as infants and children. Volunteer practitioners should be thus versed in treating pediatric patients and knowledgeable about types of post-disaster conditions they would likely treat through the mobile clinic and DAC
Three articles emphasize the importance of emergency medical records for optimizing service provision. One case study
The five case studies about evacuation following a major disaster share several characteristics and lessons learned while each report includes experiences unique to the particular evacuation. There is a clear need for prompt decisions made by the administration, coupled with an understanding of the chain of command by all involved in the disaster response
Working with the community was another topic of importance within evacuation. Pre-existing agreements with community resources and hospital facilities that could host evacuated veterans was cited as critical to the evacuation
Continuity of care, as shown in two studies, was not compromised because providers made an effort to follow patients that had been transferred to another hospital due to a loss of utilities and potential explosion
All of the studies detailed lessons learned and modifications in disaster planning that have been made since the disaster. These include increased training, stocking indoor supplies, and the development of mitigation teams that supervise improvements in disaster preparedness
A disaster response framework
Twelve of the included articles are about disaster planning and preparedness. These articles covered a wide variety of emergency management topics, though a common theme was the importance of collaboration and education
Additionally, three articles highlight the importance of VA to ensure its internal effectiveness related to disaster to be able to continue providing emergency assistance to the wider community
This literature review identified and synthesized 41 peer-reviewed articles about VA-related emergency management. The majority of articles were pre-experimental. While this affords us with detailed case studies about specific disasters, more experimental research would be beneficial. For example, evidence-based prevention programs for PTSD and other mental health issues following disaster could greatly add to the stress and coping literature on veterans and serve as the foundation for the development of effective intervention. Similarly, few studies used mixed method design. More studies on emergency management that integrates qualitative and quantitative data will afford the field with a more coherent and complete picture of its strengths and gaps. Additionally, among the phases of emergency management, there is need for more work particularly on preparedness. While twelve articles mentioned some aspect of preparedness, only two articles specifically addressed plans to handle an emergency, calling for an increased need of effective communication practices. We suggest more studies on the processes necessary for effective community collaboration and development of plans and protocols to prepare for possible emergencies.
Overall, five themes emerged from this review. The first is the effects of disaster on mental health status and services use. This group of articles point to a need for ongoing longitudinal studies on mental health impact due to disaster, as well as increased outreach efforts to victims. Also, only a few studies examined individual differences in mental health impact (e.g., ethnicity). This gap could be remedied with increased research efforts related to psychosocial risk factors and individual’s vulnerability to disaster. We suggest including ethnicity, SES, gender, and age as key variables in future research.
The second theme, effects of disaster on general health services use, highlighted the need for continuity of care. Several barriers were identified including poor communication infrastructure, although effective collaboration, such as with pharmacists, was shown to mitigate such challenges. Hospital administrators and public health officials would greatly benefit from an inclusive approach to communication practices. Related articles documented patients’ preference for receiving treatment in their community, such as through mobile clinics. This makes salient the need for support and camaraderie in disaster recovery. The need for ongoing discussion about planning for both short-term and long-term health care services was highlighted, as was greater understanding of the specific needs of the community being served.
The third theme, patient tracking, sheds light on the need for systematic protocols to organize data on patients receiving care following a disaster. Examples of successful processes were shared. These articles serve as a necessary reminder of the critical need of tracking for patient survival following disaster.
The fourth theme, evacuation, indicates an overall need for more evidence-based research, including decision-making and the roles of all personnel during disaster, including plans for ongoing collaboration and communication with city officials and local hospitals, especially as it relates to “back-up” evacuation plans. Efforts to develop plans for long-term evacuation were also deemed as critical. Careful consideration also needs to be given to identifying best practices for evacuation practices for specific, unique populations being served. Community needs assessments prior to and following disaster are thus recommended.
Articles related to disaster planning/preparation shed light on the importance of collaboration. This is particularly necessary as it relates to interrelationships between the VHA and community partners during local emergencies and federal disasters. This is also critical as it pertains to ongoing dissemination of research findings related to disaster experiences. With increased collaboration and communication, overall disaster planning and response mechanisms can be strengthened. Interestingly,this call for action reflects the mission of the Evidence Aid project
Finally, while additional research is needed within each theme identified, it is also important to note that these themes are not mutually exclusive; rather they influence each other. For example, increased tracking of services following disaster directly informs decision-making regarding service provision. Similarly, continuity of care is not merely a challenge within general health services usage, but should also be a topic of discussion within all phases of emergency management for both general and mental health services usage. An integrated, comprehensive approach to research will provide a clearer picture about the role of VA in caring for veterans during times of disaster and also about VA as a collaborator that provides support to the community before, during and after a disaster.
The authors declare the no competing interests exist
Corresponding Author: Maria Claver (mclaver@csulb.edu)