By John Palmer
No matter what hospitals do to prepare for monster hurricanes, they will never anticipate all their effects. Things will go wrong, and there will always be something that takes a facility by surprise. Hence, it’s a common tenet of emergency planning in healthcare that facilities need to try to be prepared for everything—but also have a backup plan just in case those preparations fall through. That’s definitely been branded in the minds of planners now that hospitals have weathered two storms that tested them in ways never before seen: Hurricane Katrina in 2005 and Superstorm Sandy in 2012.
Katrina hit the New Orleans area on August 29, 2005 as a Category 3 storm, and when 53 of the city’s protective levees failed as a result, almost 80% of New Orleans was left underwater, sending citizens scrambling to the roofs of their houses to escape the ﬂooding. Several hospitals were stranded, with no evacuation plans, a lack of doctors (or the inability to get staff to and from work), and failed utilities that ultimately led to many deaths of patients whose life support systems failed. The storm’s aftermath led to major overhauls in emergency preparation, and it changed the way healthcare organizations plan and drill for disasters.
Then came Sandy in 2012. The New York area generally is not a likely target for a direct hurricane strike, but Sandy made a very sudden and unexpected turn inland, coming ashore in coastal New Jersey on October 29 as a weak Category 1 storm. It sent storm surges as high as 16 feet into New York Harbor, flooding tunnels and basements and cutting power to many parts of lower Manhattan.
During the height of the storm, 12 hospitals that had originally planned to shelter in place had to completely or partially evacuate their patients, mostly due to loss of power from flooded generators or backed-up sewer systems that sent water into the lower levels. About 65 hospitals took in patients from evacuated facilities.
Storms like those are only supposed to hit once in a lifetime—but our lifetimes are proving to be different. It took Hurricane Harvey hitting Houston this past September, and the familiar sight of flooded streets and Coast Guard helicopters rescuing residents from their homes, to realize that powerful hurricanes are a part of emergency prep now and in the future.
So, the question is: Have U.S. hospitals learned the lessons necessary to make sure they can stay open during a monster hurricane? Going by what some emergency officials say, hospitals in Houston were able to prepare well ahead of Harvey and stay open despite conditions that rivaled New Orleans and New York City.
“What we learned in Katrina can be seen directly in Houston,” said William Lokey, who served as the Federal Emergency Management Agency (FEMA)’s coordinating officer for the response to Katrina, in a New York Times report. “At every level the response [was] more robust.”
The following is a primer of past lessons that have helped hospitals prepare.
Communications. It’s a law of emergency management that if you can’t communicate with the outside world, you are on your own, and that’s exactly what happened to many hospitals after Katrina struck.
Hamm says that when the power went out and phone service was cut, staff members tried to use cell phones, but downed towers from the wind and overcrowded circuits rendered them useless. There were a few satellite phones available, but to use them, staff had to go to the roof of the hospital to search for a signal.
“They weren’t adequately tested, and there weren’t any reliable antennas,” says Lee Hamm, MD, senior vice president and dean of the School of Medicine at Tulane University Medical Center in New Orleans. In 2005, Hamm was chair of one of the largest departments at Tulane, and he remained on-site throughout the entire disaster, he says. He was one of the last people to leave by helicopter evacuation, after five days without power or water. “Everyone goes through exercises thinking they are prepared, but reality is the things you didn’t anticipate are the biggest problems. We couldn’t have expected the entire city to be underwater and not be able to get things in and out.”
Today, cell networks are much more reliable, and hospitals are required to have multiple backup systems available in the event of a crisis. Emergency planning experts recommend that hospital staff train to communicate with each other and emergency responders using relatively primitive means, even pen and paper or two-way radios, in the event of a power outage.
Also, federal and local officials now work together to plan. They go through the same disaster training and largely work from the same playbook, which means they speak a common language, use the same radio equipment, and can work together—and in Houston, that meant the response was that much smoother.
By comparison, the response to Katrina was crippled by blame and miscommunication. In New Orleans, local and federal leaders grew frustrated and lashed out at each other. “We wanted soldiers, helicopters, food and water,” Denise Bottcher, press secretary for the governor of Louisiana, said about FEMA’s Katrina response in the New York Times report. “They wanted to negotiate an organizational chart.”
Resupply lines. Gone are the days of hospitals relying completely on government resources to resupply them if they become incapacitated. In 2005, FEMA was unable to get supplies into New Orleans because of a failure to properly position and mobilize resources. As a result, citizens—and hospitals—largely found themselves on their own without ways to resupply food, water, fuel, and medical supplies until National Guard troops were able to move into the city.
Houston showed that FEMA now has their act together to help hospitals. But experts still say the best way to plan is to expect to be isolated, without help, for several days in the event of a major disaster—hence The Joint Commission requires hospitals to actively monitor emergency conditions and patient needs, and determine their capabilities, including the amount of time they are capable of sheltering in place with no assistance. They recommend hospitals project out for 96 hours and plan accordingly.
That said, hospitals do still need help from the government to keep the supply lines running. During Katrina and Sandy, debris and flooding kept trucks of water, food, and fuel from reaching stricken hospitals, and few supplies had been stored beforehand at designated areas outside known flooding zones. Before Harvey struck Houston, FEMA pre-positioned supplies—a practice managers say is now standard and lifesaving because local officials no longer find themselves days away from vital resources.
Evacuation plans. One of the biggest problems experienced during Katrina was the late decision to evacuate. At both the federal level, where the government waited too long to issue an effective evacuation order for the city, and the local level, where hospitals delayed evacuating their patients and staff, those crucial decisions made the difference between being able to get ambulances and buses in for transport and having to wait for helicopters after floodwaters overtook the city.
By Sandy, healthcare had learned from the past. Hospitals in the New York City area had ambulance companies on standby long before the hurricane ever hit, just in case, and in some cases the most critical patients were moved early to inland hospitals as a precaution. The same thing happened in Houston, where ambulances were staged outside the disaster area for quick deployment.
Hospitals were left short-staffed in New Orleans when employees would not or could not report to work; now, contingencies are in place to make sure employees’ needs and the needs of their families are met. Evacuees brought to shelters in Houston found plenty of food, water, cots, and blankets. According to the Times report, “mega-shelters” were also set up in surrounding cities in case Houston’s shelters were overwhelmed.
Drills. Hospitals in Katrina found themselves crippled by a lack of preparation, with emergency and evacuation drills that had not been practiced in years. Because of this, staff had to improvise evacuations of the most critical patients, transporting them up to rooftop parking areas to await helicopter rescue.
Emergency plans now are required to include extremely detailed contingency plans. The Joint Commission and CMS require these plans to be rehearsed at least twice per year in the form of emergency exercises, and at least one of those exercises must test the hospital’s ability to handle a crisis that floods the facility with a patient surge. The idea, of course, is to make sure that staff are ready for any situation under any level of stress.
According to the New York Times, FEMA has spent more than $2 billion to train and prepare local authorities—including hospitals. At the time of Katrina, a survey by the agency found that only about 40% of communities had confidence in their plans. That number has grown to 80%, said Kathleen Fox, FEMA’s acting deputy administrator overseeing disaster preparedness, in the report.
Know who your friends are. Prior to Katrina, hospitals in New Orleans didn’t have “memorandums of understanding” with other facilities to care for patients should the need arise. In many ways, this could have helped hospitals isolated in the most heavily hit areas of the city. By Sandy, again, hospitals knew better. Facilities in New York City took in patients from facilities that were overwhelmed and had to evacuate.
Hospitals routinely train to not only sustain themselves in an emergency, but also to be ready to help out other facilities with supplies or patient care, should a sister hospital become incapacitated. This type of agreement proved helpful during the 2011 tornado in Joplin, Missouri, when an EF-5 twister wiped out St. John’s Hospital. Predetermined agreements went right into effect, allowing patients to be transferred (in many cases, by any means possible) to other hospitals. Facilities from miles away sent supplies, nurses, and volunteers to help with the response effort, taking in some of the most critically injured patients. In addition, other hospitals helped out logistically. When the tornado knocked out water pressure in Joplin, Freeman Hospital could not sterilize its medical equipment and had to send it to a hospital 20 miles to the south by couriers.
Also, hospitals shouldn’t be afraid to count on the general public. In the past, disaster management training warned against using volunteer rescuers, saying they were a potential liability. But now managers are trained to react quickly when a growing disaster overwhelms existing plans, and they have begun to see citizens as an untapped emergency force. During Katrina, authorities turned away volunteer rescuers in boats, but in Houston a literal flotilla of citizens helped evacuate flood victims and get them to hospitals. In Missouri, citizens put injured patients into the back of pickup trucks to help get them to the hospital.
“You can’t always anticipate what your needs will be, but if you have partners you can count on, that will save the day in a big way,” says Paula F. Baker, president and CEO of Freeman Health System in Joplin. Freeman took in more than 100 of the most critical patients who had been evacuated from St. John’s, but also about 1,700 patients that had walked into the ER off the streets. Emergency surgeons performed 22 lifesaving operations in the first hour after the twister struck.
Baker adds that positive relationships with hospital associations, police and fire organizations, and other state and federal emergency organizations can mean mobilizing help quicker and more effectively. “You need to think about who you will need in an emergency, and you need to make sure you have good communication and know what your facility’s limitations are,” she says.
John Palmer is a contributing writer to PSQH.
Editor’s Note: An earlier version of this article stated the Joint Commission requires hospitals to prove they can be self-reliant and operations for 96 hours during a disaster.