ARTICLE IN PRESS

International Emergency Nursing (2015)

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International Emergency Nursing

j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n

Quality of healthcare services provided in disaster shelters:

An integrative literature review
Tener Goodwin Veenema PhD, RN, MPH, MS, FAAN (Associate Professor) a,*,
Adam B. Rains MSc (Vice President) b, Mary Casey-Lockyer MHS, RN, CCRN (Disaster
Health Services Lead) c, Janice Springer DNP, RN, PHN (Volunteer) d,
Mary Kowal (Student) e
a Johns Hopkins School of Nursing, Johns Hopkins Bloomberg School of Public Health, Center for Refugee and Disaster Response, Baltimore, MD 21205, USA
b Information Technology, Tener Consulting Group, LLC, Rochester, NY, USA
c Disaster Health Services Lead, American Red Cross, Washington, DC, USA
d American Red Cross, Washington, DC, USA
e Johns Hopkins School of Nursing, Baltimore, MD, USA

A R T I C L E I N F O A B S T R A C T

Article history: Background: Globally, shelters are a resource to promote critical health and safety in disasters, partic-
Received 16 October 2014 ularly for vulnerable populations (e.g., children, elderly, chronically ill). This study examines the nature
Received in revised form 21 January 2015 and quality of healthcare services rendered in disaster and emergency shelters.
Accepted 22 January 2015
Objectives: To determine based upon systematic and accurate measurement the scope and quality of health
care services rendered in disaster shelters and to describe the health outcomes experienced by shelter
Keywords:
residents.
Disasters
Methods: An integrative review of English-language literature pertaining to the assessment, evaluation,
Emergency shelter
Healthcare services and systematic measurement of healthcare quality and client outcomes in disaster and emergency shel-
Quality ters was undertaken. Articles were identied using a structured search strategy of six databases and indexing
services (PubMed, CINAHL, EMBase, Scopus, Web of Science, and Google Scholar).
Results: Limited literature exists pertaining specically to metrics for quality of health care in acute di-
saster and emergency shelters, and the literature that does exist is predominately U.S. based. Analysis
of the existing evidence suggests that nurse stang levels and staff preparedness, access to medications/
medication management, infection control, referrals, communication, and mental health may be important
concepts related to quality of disaster health care services.
Conclusions: A small number of population-based and smaller, ad hoc outcomes-based evaluation efforts
exist; however the existing literature regarding systematic outcomes-based quality assessment of di-
saster sheltering healthcare services is notably sparse.
2015 Elsevier Ltd. All rights reserved.

1. Introduction pacted physically, mentally, and emotionally by the disaster itself

Globally, disasters are unfortunately an all too frequent event
requiring urgent intervention to prevent death and disease. In the
wake of a large-scale disaster or in anticipation of a potentially
threatening event, individuals and families may seek out, or be evacu-
ated to, disaster or emergency shelters. Those that depend most
heavily on shelters tend to be from otherwise vulnerable popula-
tions (e.g., children, elderly, and chronically ill), possess a signicant
burden of disease pre-event and may be disproportionately im-
* Corresponding author. Johns Hopkins School of Nursing, Johns Hopkins
Bloomberg School of Public Health, Center for Refugee and Disaster Response,
Baltimore, MD 21205, USA. Tel: +015854723807; fax: +014106141446.
E-mail address: tveenema@gmail.com (T.G. Veenema).
as well as relocation to a novel environment. Despite the prolifer-
ation of shelter guidelines post Banda Aceh (2004), Hurricane Katrina
(2005), and the Bam, Iran (2003) and Great East Japan (2011)
earthquakes, and a growing body of knowledge about resident char-
acteristics, there remains little documented regarding the quality
of healthcare provided in disaster shelters (Caillouet et al., 2012;
Owens et al., 2005; Takahashi et al., 2012).
Following an acute-onset disaster event, the term shelter is most
often used to represent the physical structures that are estab-
lished to provide disaster victims protection from natural elements
and also for coordination of health and social services. Shelters also
play other important roles that range from becoming central loca-
tions for communication and recovery resources to serving as staging
areas for medical treatment (Phillips et al., 2012). Ideally, shelters
should provide a safe place for individuals affected by large-scale

http://dx.doi.org/10.1016/j.ienj.2015.01.004
1755-599X/ 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Tener Goodwin Veenema PhD, RN, MPH, MS, FAAN (Associate Professor), Adam B. Rains MSc (Vice President), Mary Casey-Lockyer MHS,
RN, CCRN (Disaster Health Services Lead), Janice Springer DNP, RN, PHN (Volunteer), Mary Kowal (Student), Quality of healthcare services provided in disaster shelters: An
integrative literature review, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.01.004
 ARTICLE IN PRESS
2 T.G. Veenema et al./International Emergency Nursing (2015)
rapid onset disasters and other emergency events to reside and
seek assistance. Shelters can provide food, water, a place to sleep,
sanitation facilities and access to health and mental health ser-
vices (Phillips et al., 2012). Extensive damage to housing or shifting,
unsafe environmental conditions are the reasons individuals and
families are most often temporarily or permanently displaced. Access
to a disaster shelter for many victims may make the difference
between death and survival. In 1991 a cyclone hit Bangladesh causing
multiple fatalities, yet survival rates were high among those who
were able to reach ocial shelters. In areas with shelters there was
only a 3.4% fatality rate as compared with a 40% fatality rate in areas
without shelter access (Shultz et al., 2005). The ability to effective-
ly shelter victims of disasters is a responsibility of the respective
government along with assistance from domestic (Federal Emergency
Management Agency, 2010) and international disaster manage-
ment teams and is fundamental to any large scale response (Coppola,
2006). Governments may agree to authorize non-governmental or-
ganizations (NGOs) or the federal government to set up or to run
shelters for the affected local government, and may even subcon-
tract with those NGOs to provide both sheltering and medical care.
Ordinarily, it is only when there has been a failed government will
NGOs travel to and setup shelters on their own.
1.1. Shelter populations
Signicant attention has been paid to the client characteristics
of those displaced and receiving care in disaster shelters, particu-
larly for traditionally vulnerable populations (e.g., children, elderly,
chronically ill) who bear a higher chance of using a public shelter
(Enarson, 2010; Phillips, 2009; Wisner, 2004). Shelter residents post-
Hurricane Katrina had above average prevalence of chronic disease,
only one-half had health insurance, and over one-third received some
type of public assistance (Greenough and Kirsch, 2005; Greenough
et al., 2008). These socioeconomic factors made the shelter popu-
lations more vulnerable from the outset for adverse health outcomes.
One-half of persons residing in shelters (55.6%) after Katrina had
a chronic illness (hypercholesterolemia, diabetes, pulmonary disease,
or psychiatric illness), and among those who arrived at shelters
with a chronic disease, 48.4% lacked medication and one third lacked
a health provider (Greenough et al., 2008). This is not just an issue
in the US. For example, following the Great East Japan Earthquake
elderly evacuees and infants residing in shelters had a higher like-
lihood of contracting infectious disease (Takahashi et al., 2012).
The burden of chronic disease compounded by stress, anxiety,
grief and sleeplessness contributed to the challenges of rendering
health care services in response to the clinical needs of clients re-
siding in the Katrina shelters (Phillips et al., 2012). Clinicians provided
multiple health care services ranging from rendering basic rst
aid, to more advanced chronic disease management. The interplay
of poverty, long standing health conditions and psychological trauma
is reported to create a network of vulnerability for poor health
outcomes in victims of disaster events (Evans, 2010).
1.2. Types of disaster shelters
Multiple types of disaster shelters exist and they operate under
the auspices of a variety of governmental and voluntary organiza-
tions. Under the U.S. National Response Framework (NRF) as
described in Emergency Support Function 6 (ESF-6) the American
Red Cross (ARC) is the support agency designated as responsible for
sheltering and mass care. ARC operates under a congressional
mandate to provide shelters following natural disasters and other
extreme events with support from the Federal Emergency Man-
agement Agency (FEMA). ARC establishes and operates approximately
60% of all disaster shelters in the U.S. with the balance sponsored
by government, other non-governmental and faith-based organi-
Please cite this article in press as: Tener Goodwin Veenema PhD, RN, MPH, MS, FAAN (Associate Professor), Adam B. Rains MSc (Vice President), Mary Casey-Lockyer MHS,
RN, CCRN (Disaster Health Services Lead), Janice Springer DNP, RN, PHN (Volunteer), Mary Kowal (Student), Quality of healthcare services provided in disaster shelters: An
integrative literature review, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.01.004
zations (Homeland Security Institute, 2006; Chandra and Acosta,
2009). Internationally, shelters are operated by a collection of local
governmental and global humanitarian response NGOs and may
range from make shift huts to fully deployable rapid assembly shel-
ters (DRASH) (Owens et al., 2005).
Disaster shelters may also be referred to as emergency or tem-
porary shelters, those transitional places where people can go for
short periods of time for protection and to ride out the event. Some-
what more ephemeral in their being, emergency shelters can be
adapted to local conditions and circumstances such as a tent set up
in a eld or a structure under a bridge (Phillips et al., 2012). Con-
ceptually, these temporary shelters are established based upon the
assumption that disaster impacted victims will likely return to their
homes quickly (Babister and Kelman, 2002). Temporary shelters may
include General Population (GP) shelters for the public at large or
Functional/Medical Needs Shelters (FN) for individuals that require
a higher level of care (Phillips, 2009; Phillips et al., 2010).
In 2010 FEMA issued its Guidance on Planning for Integration of
Functional Needs Support Services in General Population Shelters, com-
monly referred to as the FNSS, dramatically changing the way disaster
shelters are operated in the U.S. The FEMA guidelines were estab-
lished to provide protections for individuals who have access and
functional needs and to ensure that they receive lawful and equal
assistance before, during, and after disaster events and large scale
public health emergencies. The guidelines mandate that Function-
al Needs Support Services (services that enable individuals with
access and functional needs to maintain their independence in a
general population shelter) be incorporated into all existing shelter
plans, regardless of how the shelter is categorized. The purpose of
the mandate is to make sure that persons with functional needs can
be accommodated in U.S. general population shelters and are not
refused because of specic functional disabilities (blind, hearing im-
paired, walking impaired, etc.) and not become a burden to other
higher level medical needs shelters.
Recent international disasters such as the Philippine typhoons
(2013 and 2014) and the Syrian ooding and mudslides (2014) have
underscored the importance of emergency coordination of mass care
and sheltering following rapid onset events, yet standards for de-
livering, providing and evaluating this care are not well articulated.
The December 2014 release of the Core Sphere Humanitarian Stan-
dard for Quality and Accountability provided an update to the Sphere
Humanitarian Standards Project designed to provide a baseline for
the international public health care of victims of disasters.
This integrative review of the existing literature focuses on as-
sessment, evaluation, and systematic measurement of healthcare
services quality and client outcomes in disaster or emergency
shelters resulting from rapid or acute-onset events. We hope this
information will be an important foundation in deriving consen-
sus around domestic and international practice guidelines.
2. Materials and methods
An integrative review of the literature was conducted on two
specic concept areas relating to the overarching topic: literature
pertaining generally to nursing and/or health care in emergency
or disaster shelters, and any systematic assessment, evaluation,
quantitative model, outcomes, or metrics for measuring quality of
care in this context. An integrative review of the literature repre-
sents a specic design methodology that summarizes past empirical
or theoretical evidence in order to provide a better understanding
of a particular phenomenon or healthcare problem (Broome, 1993,
p. 231). Integrative reviews differ substantively from systematic
review and meta-analyses approaches that rely on the combina-
tion of evidence and may overemphasize the randomized clinical
trial and hierarchies of evidence (Evans and Pearson, 2001; Kirkevold,
1997). The integrative review allows for the simultaneous inclu-
 ARTICLE IN PRESS
T.G. Veenema et al./International Emergency Nursing (2015) 3

sion of diverse methodologies (i.e. experimental and non-

experimental research) in order to more fully investigate and
understand a phenomena of concern (Whittemore and Kna, 2005).
Well-done integrative reviews, thus, have the potential to build the
science, informing research, practice, and policy initiatives
(Whittemore and Kna, 2005).

2.1. Search strategy

A series of comprehensive searches for relevant English-language

literature was performed using six popular publication database and
indexing services (PubMed, CINAHL, Scopus, EMBase, Web of Science,
and Google Scholar). Initial search terms were obtained from MeSH
(Medical Subject Heading) nomenclature and selected sentinel pub-
lications then mapped to appropriate database-specic terminology
(subject headings, categories, and keywords). The nal pool of terms
was used to conduct inclusive title, subject, keyword, and full text
searches in each of the six listed databases. Papers matching any
combination of terms from the two concept areas were retrieved
for review. Additional candidate studies were identied through a
manual search of emergency shelter and disaster preparedness
literature, via discussion with other authors in the eld, and from
the reference lists of publications retained for full review.

2.2. Screening and review

All candidate literature was subject to independent title, ab-

stract, and nally full-text review by two or more authors according
to a series of established criteria (Table 1). A vote from any one author
was deemed sucient to retain a paper during title and abstract
review, while a consensus of two or more authors was required for
retention during full text review (Figure 1). Studies were excluded
that did not relate to disaster shelters or healthcare in shelters,
were not original research, were war or human conict-related, or Fig. 1. Literature screening and review process.

included demographic and prevalence data only (Table 2). Studies

retained for inclusion in this paper were reviewed by all authors,
summarized, and study quality was assessed using the Crowe
Critical Appraisal Tool (Crowe et al., 2012).
3. Results
From the original search pool of 517 papers, 13 articles were
selected for review (Figure 1). All but one study was conducted in
the U.S. While none of the articles in the search pool directly ad-
dressed a systematic assessment of quality of care in disaster shelters,
the papers selected for inclusion did more broadly address health-
care delivery in this context. Despite an absence of date restrictions
on our searches, the included papers span from 2007 through 2012.
Upon repeat of the search strategy in late December 2014, one
additional international article was identied for inclusion. Five of
the nal fourteen articles were categorized as qualitative studies,
six were quantitative studies, and three employed mixed methods
(Table 3).
Data analysis was undertaken using content analysis methods.
Content analysis looks to identify core consistencies and mean-
ings (Patton, 2002) and to elucidate key patterns, themes and
categories (Miller and Alvarado, 2005). The results are summa-
rized below and categories were extracted pertaining to the major
issues identied relating to quality of health care services: staff/
preparedness, medications/medication management, infection
control, referrals, communication, and mental health.
3.1. Stang and preparedness
Studies cited both stang numbers and health staff prepared-
ness as critical issues in shelter health care. Shelters surveyed by

Table 1
Literature search strategy.

Concept area keywords PubMed CINAHL Scopus EMBase Web of Science Google Scholar

A Disasters, Disaster, Natural Disaster, Mass Casualty Incident, 66,318 21,476 49,981 34,025 110,594 ~1.8 mil
Relief, Disaster Preparedness, Disaster Response
B Emergency Shelter, Shelter, Internally Displaced Persons, 3254 992 12,816 3681 92,073 ~181,000
Disaster Shelter
C [A and B] 264 114 839 272 513 ~65,600*
D Quality of Healthcare, Quality, Model, Metric, Outcome, ~4.8 mil 64,833 327,811 ~2.4 mil 517,810 ~2.76 mil
Evaluation, Assessment, Measure, Indicator
E [A and B and D] 97 2 18 42 219 >4100*
Retrieved from C and E for review process 97 23 31 40 226 100

* Top 100 hits (sorted by relevance) reviewed for inclusion.

Key search terms are in bold.

Please cite this article in press as: Tener Goodwin Veenema PhD, RN, MPH, MS, FAAN (Associate Professor), Adam B. Rains MSc (Vice President), Mary Casey-Lockyer MHS,
RN, CCRN (Disaster Health Services Lead), Janice Springer DNP, RN, PHN (Volunteer), Mary Kowal (Student), Quality of healthcare services provided in disaster shelters: An
integrative literature review, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.01.004
 ARTICLE IN PRESS
4 T.G. Veenema et al./International Emergency Nursing (2015)

Table 2
Search terms and review criteria.

Search terms

Disasters: Disaster, Natural Disaster, MCI, Relief, Disaster Preparedness, Disaster Response, . . .
Emergency Shelter: Shelter, Internally Displaced Persons, Disaster Shelter, Temporary Shelter, . . .
Quality of Healthcare: Care, Quality, Model, Metric, Outcome, Evaluation, Measure, Indicator, . . .

Inclusion criteria Exclusion criteria

English language Not related to disaster shelters

Qualitative or quantitative data Not related to healthcare and prevention in disaster (acute onset) shelters
Outcome measure is related to quality of care in disaster shelters Related to war or complex human emergency
or metrics that can be used to measure such
Population: shelter residents, shelter staff, experts in the eld Client demographic and prevalence data only
Not original research (editorial or commentary)

Table 3
Literature summary table.

Citation Type of Type of Study purpose N Population Sample Quality

report data design score (%)

Brahmbhatt et PR research QL Evaluate the level of public health preparedness 43 Health staff members from shelters Convenience 93
al., 2009 article among responders and identify in 5 ARC regions in Texas sample
recommendations to improve public health
preparedness in future mass displacement
situations
Caillouet et al., PR research QL/QN Understand and characterize the medical needs 3329 Evacuees receiving medical care at All available 90
2012 article of evacuees and those receiving care at shelters shelters and ad hoc medical clinics triage records
and temporary medical facilities following a following Hurricanes Katrina and and treatment
hurricane Rita. notes
Currier et al., PR research QN/QL To describe the experience of organization, 2299 Patients seen at the clinic with Convenience 88
2006 article stang, and administration of the Katrina medical records available for sample
Clinic at the Mississippi State fairgrounds analysis
shelter.
Deal et al., PR research QL To describe the positives and negatives of 10 Community nurse volunteers and Convenience 85
2006 article special-needs shelter nursing so others can learn volunteer nursing faculty members sample
from the experience. who worked in special-needs
shelters in Texas after Hurricane
Rita in 2005
Faul et al., 2011 PR research QN To describe the type, extent, and location of 1130 Hurricane Katrina evacuees All injury 92
article injuries treated among shelter evacuees at the receiving medical treatment for treatment
Astrodome and contrast this with patterns in the injuries at the Houston Astrodome records
general US population. mega-shelter (September 2005).
Inoue et al., PR Research QL To assess survivors post tsunami health and 236 236 shelter clients (evacuees) Convenience 75
2014 Article nutritional status 1 month after the disaster residing in a school shelter in sample
residing in a school based shelter Ishinomaki City Japan.
Kishimoto and Report QL Discussion and review of lessons learned and NA Tsunami evacuees and shelter NA 80
Noda, 2013 special considerations regarding diabetes care residents with diabetes.
drawn from the Great East Japan earthquake/
tsunami (2011).
Missildine et PR research QN/QL To describe the experience of evacuees with 82 Evacuees who resided at the Convenience 93
al., 2009 article special medical needs in a shelter in Texas after medical special needs shelter at UT sample
Hurricane Gustav in 2008. Taylor.
Murray et al., PR research QN To describe the development and 29,478 Shelter clients residing in the All consenting 90
2009 article implementation of a symptom-tracking Houston Astrodome and Reliant clients were
surveillance system used for potential outbreaks Park shelter after Hurricane included.
in the Houston Astrodome and Reliant Park Katrina in 2005.
shelter.
Noe et al., 2013 PR research QN To describe and the injuries and illnesses treated 3863 Clients treated by the ARC using All available 100
article by the ARC in shelters and by teams in LA, MS, the client health record and the client records
TN, and TX after Hurricanes Gustav and Ike. Aggregate Morbidity Form. were included.
Phillips, 2009 PR research QL To understand how shelters were opened and 82 Shelter managers in TX, LA, MS Randomized 88
article operated when traditional providers are stratied and
overwhelmed. spatial zone
sampling
Rebmann et al., PR research QL To outline the educational and resource gaps 3 APIC members attending the 2006 Consecutive 100
2008 article that exist during disaster response as well as to National APIC Conference sampling
learn from the public health and infection
control experiences of past disasters.
Suzuki et al., PR Research QN To examine the clinical manifestations of shelter 17 17 shelter clients transferred to Convenience 70
2011 article acquired pneumonia in refugees transferred to a Tohoku University Hospital for SAP sample
back up hospital in Japan following an
earthquake in 2011.
Yee et al., 2007 PR research QN To assess the spread of norovirus and the 1173 Clients triaged at the Reliant Clinic All available 95
article methods used for infection control at the Reliant for gastroenteritis from September client records
Park Complex in Houston following Hurricane 2 to 12, 2005. were included.
Katrina.

Please cite this article in press as: Tener Goodwin Veenema PhD, RN, MPH, MS, FAAN (Associate Professor), Adam B. Rains MSc (Vice President), Mary Casey-Lockyer MHS,
RN, CCRN (Disaster Health Services Lead), Janice Springer DNP, RN, PHN (Volunteer), Mary Kowal (Student), Quality of healthcare services provided in disaster shelters: An
integrative literature review, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.01.004
 ARTICLE IN PRESS
T.G. Veenema et al./International Emergency Nursing (2015)
Brahmbhatt et al. (2009) had nurses (RN, LPN, NP) present at 93%
of sites, more than half the shelters (55.8%) were staffed with rst
responder staff (emergency medical technicians and paramedics),
and 39.5% had volunteer physicians available (Brahmbhatt et al.,
2009). Phillips et al. (2012) found that traditional shelters (ARC
managed) were most likely to have healthcare professionals on site
in comparison with emergent and transitional (smaller faith-
based, some ARC support) shelters which often had to transport
clients to clinics (Phillips et al., 2009, 2012).
Brahmbhatt et al. reported that while 79% of shelter staff inter-
viewed had received some formal training from the American Red
Cross (ARC), only 48% considered their training was adequate. Less
than one-third of shelter health staff had public health training,
and only 55% had received public health information specic to
managing the health needs of evacuees (Brahmbhatt et al., 2009).
A survey of small medical-needs shelters by Deal et al. (2006)
highlighted problems with identifying shelter personnel authori-
ty, and scope of practice issues (responsibility qualications, and
competencies) as it was often unclear who was in charge and who
could perform treatments safely and legally (Deal et al., 2006). Ver-
ication of clinical skills and licensures to appropriately assign care
and tasks to volunteers was problematic. There was no clear coor-
dinator of the nursing care to make assignments or to schedule
volunteers for shifts (Deal et al., 2006).
3.2. Medications/medication management
Procurement of and access to medications were consistently
identied as problematic for Hurricane Katrina shelter clients who
left their homes without their medications, nished the prescrip-
tion during displacement, and who needed new medications
prescribed (Currier et al., 2006). They noted that the majority of
clients at the Katrina shelter had left their homes with only enough
prescription medications to last for a day or so (Currier et al., 2006).
Over 17 days, the shelter staff lled 4902 prescriptions, with new
medications for anxiety and depression more frequently written as
time progressed (Currier et al., 2006). Diculties in achieving and
maintaining glucose control and the management of hyperten-
sion have been reported in diabetic shelter residents lacking
medications (Kishimoto and Noda, 2013).
In addition to providing and lling prescriptions, medication man-
agement for special-needs clients was also cited as dicult in shelter
settings. For those unable to self-medicate, management was
dicult to coordinate for staff. One solution was to group the medi-
cations and use digital pictures to identify clients (Deal et al., 2006).
Missildine et al. (2009) noted that in a medical special needs shelter,
63% of clients reported requesting help with their medications and
management and 99% received the assistance necessary.
3.3. Infection control and surveillance
Only 37% of shelters surveyed by Brahmbhatt et al. (2009) had
a system in place for screening clients upon arrival to the shelter
and no public health providers were present, instead relying on
shelter managers and health staff (Brahmbhatt et al., 2009). In con-
trast, Murray et al. (2009) describe the surveillance system deployed
at the Astrodome and Reliant Park Complex following Hurricane
Katrina. Clients were interviewed daily using a cot survey tool to
track symptoms and identify potential referrals (Murray et al., 2009).
Evaluation of clinic records at the Reliant Complex revealed that in
a 10-day span, 17% of clinic visits were for gastroenteritis. Public
health ocials put interventions in place to prevent the spread of
the illness. These included food-preparation precautions, proper
treatment and storage of water, environmental management and
cleaning, disinfection of surfaces, day care areas, and lines, as well
as isolation of ill clients and proper hand hygiene (Yee et al., 2007).
Please cite this article in press as: Tener Goodwin Veenema PhD, RN, MPH, MS, FAAN (Associate Professor), Adam B. Rains MSc (Vice President), Mary Casey-Lockyer MHS,
RN, CCRN (Disaster Health Services Lead), Janice Springer DNP, RN, PHN (Volunteer), Mary Kowal (Student), Quality of healthcare services provided in disaster shelters: An
integrative literature review, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.01.004
5
They were unable to determine which of these interventions had
a direct effect on disease reduction, but rather cited a combined
effect. Inoue et al. (2014) also noted increased gastrointestinal disease
related to nutrition and quality of food intake in a school based
disaster shelter (Inoue et al., 2014).
Noe et al. (2013) tested the use of an aggregate reporting form
as a means of tracking public health concerns as well as health care
delivery issues. Most complaints were for acute minor illnesses, the
majority being pain and respiratory (Noe et al., 2013). Focus groups
composed of members of the Association for Professionals in In-
fection Control (APIC) felt that attention to infectious disease often
fell by the wayside in disasters while shelter, food, and water took
priority for responders (Rebmann et al., 2008).
3.4. Referrals
When healthcare providers at shelters are unable to successful-
ly treat a client, outside referrals to higher level or emergency health
care services are made. Referrals made to higher levels of care were
made for approximately 35% of the locations assessed by Noe et al.
(2013) Of these, 42% were hospital/emergency department/clinic
referrals, 24% were pharmacy referrals, and 23% were physician re-
ferrals (Noe et al., 2013). Suzuki et al. (2011) reported that cases
of shelter-acquired pneumonia referred to hospitals following a cat-
astrophic earthquake in Japan could be attributed to poor shelter
conditions, cold temperatures, poor oral hygiene, and under-
nutrition (Suzuki et al., 2011).
3.5. Communication
APIC members cited poor communication as one of the major
challenges to disaster response. Focus groups recommended im-
proved and consistent messages to the public, as well as enhanced
communication in shelters in the form of a daily sit down
(Rebmann et al., 2008). In relatively small, specialized shelters,
communication was a constraint on nursing care. Deal reports that
new nurses had to continuously be oriented to the shelter and im-
portant information was lost in hand-offs. A central communication
log or record was suggested as a way to improve and maintain
consistent communications (Deal et al., 2006).
3.6. Mental health
Mental and psychiatric illnesses were identied as major health
care service concerns in disaster shelters, with mental health care
identied as one of the most important issues in disaster-stricken
areas (Kishimoto and Noda, 2013). Shelter clients experience
emotional responses such as grief, loss, fear, anger and for some,
guilt over surviving the death of a loved one (Kishimoto and Noda,
2013). Brahmbhatt et al. reported that volunteer health personnel
were able to correctly identify scenarios with clients needing emer-
gency psychiatric services 74% of the time, in comparison with 90%
for medical cases (Brahmbhatt et al., 2009). Mental health practi-
tioners are not guaranteed at shelter sites as Phillips et al. (2012)
notes that only 6 of 82 shelters included had a mental health pro-
fessional on site. To ll this void, shelter managers reported shelter
staff or clergy sometimes provided personal counseling.
4. Discussion
The primary objective of this review was to identify what is cur-
rently published in the nursing and medical literature regarding the
scope and quality of care provided in disaster or emergency shel-
ters and to identify metrics for quality assessment. Our results were
disappointingly limited. No studies addressed these issues direct-
ly, nor did they provide evidence of the metrics we were seeking.
 ARTICLE IN PRESS
6 T.G. Veenema et al./International Emergency Nursing (2015)
Additionally, the majority of the studies were U.S. based and thus,
not representative of an international perspective. The results did
suggest important components of care quality that could be used
to derive appropriate measures and items for quality improvement.
Based on this review, appropriate stang and health care pro-
vider preparedness can be important indicators of quality of care
rendered in disaster shelters. Adequate training as well as qualied
staff would ensure that the best providers and staff are available
(Association of Public Health Nurses 2014). Optimal stang numbers
are also an important consideration for providing care to a vulner-
able population. In reality, the stang and human resource
management of disaster shelters is as variable as the multiple numbers
of organizations who establish and maintain shelter operations.
Shelters are established, maintained and closed down based upon
the guidelines of the organization that is sponsoring the shelter,
frequently in conjunction with or at the request of local and state
governmental emergency management decisions. Shelters may be
closed due to the direction of local emergency management and other
regulatory bodies.
While many consider disaster shelters displaced neighbor-
hoods of convenience in reality following large scale acute-onset
events they are more often satellite congregate health care settings
frequently functioning under the radar of the normal regulatory over-
sight of the local health care systems. Normally in the US, State Health
Departments license health care facilities and provide oversight of
the individuals, activities and services rendered. There are specic
policy protections available for those who provide health care in an
unlicensed environment. In the event of a Presidential disaster dec-
laration under the Robert T. Stafford Act and when the HHS Secretary
declares a public health emergency under Section 319 of the Public
Health Service Act, the Secretary is authorized (under section 1135
of the Social Security Act) to take actions including to temporarily
waive or modify certain Medicare, Medicaid and Childrens Health
Insurance Program requirements to ensure access to sucient health
care services to meet the needs of individuals enrolled in Social
Security Act programs during times of disaster (Centers for Medicare
and Medicaid, 2009). The purpose of these waivers however is driven
by reimbursement and the desire for freedom from Emergency
Medical Treatment and Labor Act (EMTALA) sanctions. Historically,
health care services rendered within the context of a disaster setting
(e.g. shelter) are never pursued for reimbursement, thus federal
payment waivers are not requested. This U.S. policy conundrum may
contribute to the current situation where metrics for the measure-
ment of quality of health care services in disaster shelters is not
mandated.
Internationally, the situation is more complex and often country
or region specic.
Access to medications and lling of necessary rells might be
another important predictor of care at shelters. As many clients arrived
in need of medications for chronic illness, as well as acute health care
needs, this becomes critical to wellness. Writing and lling prescrip-
tions also indicates that supply systems are in place for medication
procurement and distribution.
Review of the existing literature suggests that infection control
and food safety might be one of the most accurate indicators of care
in shelters. The Centers for Disease Control and Prevention have issued
guidance documents specic to disaster relief and for healthcare
professionals (CDC, 2005) as well as provide a surveillance report-
ing system for use in disaster shelters (CDC, 2006) and a tool for
conducting disaster shelter assessments (CDC, 2008). Update and
redesign of the surveillance reporting system for disaster shelters
was conducted in 2013.
While surveillance and tracking via medical records can be useful
in high population shelters, the ongoing and systematic physical as-
sessment and tracking of individuals residing in shelters by licensed
health care providers knowledgeable regarding public health is
Please cite this article in press as: Tener Goodwin Veenema PhD, RN, MPH, MS, FAAN (Associate Professor), Adam B. Rains MSc (Vice President), Mary Casey-Lockyer MHS,
RN, CCRN (Disaster Health Services Lead), Janice Springer DNP, RN, PHN (Volunteer), Mary Kowal (Student), Quality of healthcare services provided in disaster shelters: An
integrative literature review, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.01.004
critical to the prevention of disease outbreaks (Brahmbhatt et al.,
2009). Cot-to-Cot (Springer, 2012) assessment and surveillance
interviews will not only identify possible outbreak situations, but
also clients in need of care or referral.
Appropriate referrals to authorities can help to ensure that public
health concerns are addressed and monitored. Referrals to medical,
psychiatric, or pharmacy care can also provide good information re-
garding care. Ideally, the appropriateness of these referrals would
be veried via record review of patient disaster charts.
The need for mental health services suggests that the presence
of a mental health professional(s) on site at a shelter would improve
quality and completeness of care. Finally, given the concerns regard-
ing communication between providers and health care organizations
regarding shelter clients and public health reporting, a system to
address these issues would be another measure to consider when
measuring quality.
4.1. Limitations
The results of our study are limited by the small number of
studies in existence that addressed our topic, and by the level of
available evidence. Not all of the studies clearly dened the cate-
gory (type) of the disaster shelter where the study took place, and
different frameworks for investigation were employed further lim-
iting auditabilty and reproducibility. Additionally the 2010 U.S. FNSS
guidance (Federal Emergency Management Agency, 2010) regard-
ing the use of the term medical/special needs shelter added to the
complexity of measuring scope and quality of health care services
across time and across various shelter types. As the majority of the
studies were U.S. based, generalizability to international disaster set-
tings may be limited. Finally, the internal validity of a review of the
literature is always subject to both selection and publication bias.
This review presented information based upon a limited number
of published studies. In fact, much is currently known about health
services in disaster shelters but exists outside of the published peer
reviewed journals that the authors studied. Much of what is known
exists in books, manuals, eld guides and even government pub-
lications, and is practical experiential knowledge.
4.2. Future directions
The ndings of this integrative review suggest that prior to imple-
menting initiatives directed towards measurement of health care
services rendered, a tremendous need exists to rst and foremost de-
scribe the care that is being provided in disaster shelters both in the
United States and internationally. Obtaining consensus among gov-
ernment and non-government organization on the types, frequency,
duration and documentation of health care services as well as type
of providers rendering health care services in disaster shelters is crucial.
Only with this foundational knowledge can we begin to move towards
measurement of quality and effectiveness. Efforts should be made to
accurately document and describe the care being rendered so as to
improve our understanding of the scope and intensity of health care
services environment in disaster shelters across the globe.
The lack of evidence supporting the measurement of health care
services rendered in disaster shelters is in many ways not surpris-
ing, given the variability across shelter settings and the fact that
the American Red Cross and many other international disaster
services organizations continue to collect data via paper client records
that are currently stored within local or regional chapters. In many
international disaster settings there may be minimal to no docu-
mentation at all of health services rendered. Clearly, rapid and
comprehensive improvements in information technology are needed
in order to enable the collection of disaster shelter data in a mean-
ingful way. In order to measure the amount and effectiveness of care
rendered, organizations need to be able to collect, collate, analyze
 ARTICLE IN PRESS
T.G. Veenema et al./International Emergency Nursing (2015)
and optimally share information in real time and across agencies.
Data collection needs to be done in a timely, valid and reliable
manner. An international universal measurement tool should be
developed and validated for use in disaster shelters.
Finally, within the U.S. there exists a need to develop national
standards specically addressing care for disaster shelters. While
many disaster shelters do not include the provision of direct health
care services to clients, some do and are, in essence, providing health
care in an unlicensed environment. Variations in the provisions
within State health care laws may exist. The development of na-
tional standards for health care services rendered in the context of
disaster sheltering can play a signicant role in ensuring the quality
and effectiveness of care rendered, with the goal of improving
population-based health outcomes. The Sphere Core Humanitari-
an Standards for international disaster response provide an example
for benchmarking public health management guidelines in large scale
disaster response (The Sphere Project 2014).
5. Conclusions
Disaster events impact all regions of the world and have a pro-
found effect on the health, economic and social life of individuals
and populations. For many victims disaster shelters provide a safe
haven and access to health care and mental health resources. This
study revealed that a small number of population-based and smaller,
ad hoc outcomes-based evaluation efforts exist; however the ex-
isting literature regarding systematic outcomes-based quality
assessment of disaster sheltering healthcare services is notably
sparse. Emergency nurses contribute to the provision of health
care services in disaster shelters and are uniquely positioned to ad-
vocate for additional research addressing clinical excellence in patient
care following large scale disaster events. In order to optimize
population health outcomes for displaced disaster victims locally
and internationally, government and humanitarian NGOs need key
health outcomes indicators and a systematic measurement process
to monitor and evaluate the quality of care in shelters.
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