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Disaster Planning: What Have We Learned?

by Emily Friedman

First published in Hospitals & Health Networks OnLine, August 1, 2006

This month marks the one-year anniversary of Hurricane Katrina's landfall; Rita and Wilma hit soon afterward. The brutal legacy of these storms follows that of other hurricanes, earthquakes and floods that have put health care professionals to the test. Here are some lessons from people who were there.

On Aug. 29, 2005, Hurricane Katrina made landfall on the Gulf Coast, and changed the consciousness of Americans forever. Since then, millions of words (including some of mine) have been written about Katrina and its sister storms--what went right and wrong, what was achieved, the heroism of most of the health care workers on the scene, the inexcusable callousness of a few.

In the intervening year, I have been privileged to hear superb presentations by some of those who were at ground zero. These talks were of particular importance to me because in 1994, in the wake of a string of calamities (an earthquake, two hurricanes and a six-state flood), I wrote a comprehensive piece for the Journal of the American Medical Association on disaster planning (JAMA, Dec. 21, 1994, vol. 272, no. 23, pp. 1875-1879). That research led to my long-term interest in the subject.

Since the horrific Gulf Coast storm season, many lessons have been shared by people who were working with a bird's-eye perspective, and what was learned is obviously critically important: the failure of government at all levels to respond effectively, the abysmal performance of the Federal Emergency Management Agency (boy, have I heard a lot of FEMA jokes in the last year!), the uneven work of private charities and all the rest. But what was learned by health care professionals during those awful weeks is every bit as relevant, if not more so, because they had lives directly in their hands.

And so, as the anniversary approaches, here are 15 lessons from people who lived and worked through the horror and who are willing to teach the rest of us.

Facility Issues

Make plans with other facilities. John Matessino, president of the Louisiana Hospital Association (LHA), reminds us that health care facilities must make arrangements to work with each other, no matter what the competitive environment. One hospital might have a better communications system; a long-term care facility might be on higher ground; a clinic might be better located for receiving evacuees. Take a "time out" and meet with other providers in your region to discuss who is best equipped to do what in the event of a calamity.

Work with your associations as well; the LHA has been praised by hospitals for its peerless support during and after the storms, including helping providers evacuate patients, keeping lines of communication open, dealing with news media and managing supply issues.

Be prepared for refugees, some of them in great need. Teri Fontenot, president and CEO of Woman's Hospital in Baton Rouge, La., was lucky that her facility was not in the paths of the storms. But in the days following Katrina, the population of Baton Rouge was doubled by refugees. Woman's Hospital, which has 300 staffed beds and an 82-bed neonatal intensive care unit, found itself the provider of refuge for thousands of patients. At the height of the post-Katrina diaspora, its NICU had 125 patients, and on one memorable day, the hospital delivered 49 babies. In the month after the storm, Woman's treated more than 1,100 patients, delivered more than 150 babies and coordinated care for 121 evacuated infants. The social services staff did everything from finding shelter for mothers and children to arranging for funerals for six infants who did not survive.

Fontenot reports that the biggest challenges were communications problems, lack of medical transportation, insufficient shelter space for pregnant women and new moms, and the absence of dedicated phone numbers so that callers knew whom to contact. She adds that electronic health records would have been extremely helpful.

How will your physical plant perform in a crisis? During the 1994 Northridge earthquake in Southern California, several hospitals were damaged. At St. John's in Santa Monica, then-CEO Sister Marie Madeleine Shonka reports that the emergency generators worked, but they did not necessarily provide power to contiguous areas of the facility. As a result, hospital employees and physicians had to try to make it from one lighted, powered part of the building to another through dark areas, some cluttered with debris. Sister Shonka's advice: Know which areas are served by generators, and which are not, and stock axes, heavy gloves and flashlights in areas through which employees and physicians may need to work their way.

Equally important, know how your water system works. In many emergencies, the water supply is likely to be disrupted or polluted. You may need to limit water use to critical areas in the facility. Matessino adds that wells use electricity, and if there is none, the pumps won't work.

Be prepared for a communications meltdown. We depend on our cell phones, but they, in turn, are dependent on a network that may fail. In the aftermath of Hurricane Iniki in Hawaii, the president of the Hawaii Association of Hospitals, Rich Meiers, was able to arrange communications for hospitals on the badly damaged island of Kauai through a military satellite hookup--via Alaska! One Louisiana hospital, cut off after Katrina, was able to communicate only through the OnStar technology in a nurse's car. Matessino reports that the most reliable forms of telecommunication in a crisis are ham radios and some satellite-based systems.

Patient Care Issues

Make sure patients who need daily medication have access to it. One of the great stories of heroism after Hurricane Andrew was that of members of the medical staff of Memorial Regional Hospital in Hollywood, Fla., who, realizing that all the pharmacies were gone in the affected area, were concerned about patients who needed daily medication. John Combes, M.D., (now president of the Center for Healthcare Governance at the American Hospital Association) and his colleagues obtained medications from the hospital pharmacy, piled into a van and spent days in the flattened Homestead area, dispensing critical drugs to people who had no other recourse--undoubtedly saving many lives.

Patients with AIDS, cancer, congestive heart failure, hypertension, diabetes and many other conditions may not be able to wait until transportation to the nearest functioning pharmacy is available.

Know where dialysis patients and others who need immediate therapy are and have access to the information. We are moving toward a paperless health care world, but it is necessary to think about information that you must have if there is a cataclysmic outage of electrical power. When Iniki hit Kauai, there was no paper list of patients with kidney failure. That forced health care workers to go door to door in devastated neighborhoods to find out who was in need of dialysis or other immediate therapies.

Of course, such information is backed up electronically these days, but it does no good if it can't be accessed. It wouldn't hurt to have a paper list, just in case.

In an evacuation, it may be best for the sickest patients to leave first. Traditional disaster planning tells us to discharge all the ambulatory patients first and leave the sickest for last. Although the New Orleans disaster was unique, it did teach us that leaving the most severely ill for last might mean that they don't get out at all.

Karen Sexton, R.N., Ph.D., vice president and CEO of the University of Texas Medical Branch in Galveston, Texas, was given but a few hours to evacuate her facility when it looked like Hurricane Rita was headed straight for Galveston. That low-lying city has a dreadful history of hurricane deaths, the most notable being the demise of 8,000 people in the horrible storm of 1900.

Sexton, turning traditional wisdom on its head, declared that the sickest were to be evacuated first. Fortunately, Rita did not hit Galveston, but Sexton's rewriting of the rules could save lives in the future. It certainly might have saved the helpless nursing home patients at St. Rita's in New Orleans, who were left to drown--and did.

Medical records must accompany patients. Patients from the affected regions of Louisiana were sent to at least 32 states, according to Matessino. In all too many cases, despite the best efforts of the hospitals, they were evacuated without their medical records and sometimes without any identification, and their families had no idea where they had gone. Sexton, having learned from this, insisted that the medical records of every patient be physically attached to that patient prior to and during evacuation. That undoubtedly cut down on the massive amounts of time that had to be spent by caregivers in receiving hospitals to take histories and conduct tests to determine patients' health status when no information about them was available. As many analysts have observed, this provides a powerful argument for electronic medical and health records.

Take the issue of pets seriously. In the aftermath of Hurricane Andrew, Sarah Grim, then president of the South Florida Hospital Association (now the South Florida Hospital and Healthcare Association), who is now a consultant on disaster planning, warned that many people will not leave threatened areas without their pets. Too bad nobody paid attention, especially FEMA; allowing people to bring their animals with them would have saved hundreds of lives on the Gulf Coast. We have learned the hard way that many folks would rather stay and take their chances than abandon their dogs, cats, birds, lizards or other animal friends. Indeed, both patients and staff brought their pets to hospitals during the Gulf Coast storms, refusing to leave them behind. Include pets in your planning; you will save both human and animal lives.

(Two best pet stories I have heard from the Gulf Coast: First, on a bus of evacuees from Louisiana to Houston, some children smuggled their pets, including--don't ask me how they did it--two hermit crabs. And Best Friends, a pet rescue organization whose volunteers did truly heroic work after Katrina, asked on its Web site for foster homes for some small, furry critters that had been rescued from New Orleans: 15 exotic tarantulas. I don't know if they had any takers.)

Staff-Related Issues

Keep your staff informed on as timely a basis as possible. Needless to say, most staff members will do whatever is necessary in times of disaster; there are no adequate words of praise for what these people have done. But it helps if they know what is going on. Through whatever means you have--even if it's OnStar--let them know the status of things, how their neighborhoods are, what resources are available, what the evacuation plans are and anything else they need to know. Both Matessino and Sexton urge that rumors be monitored and addressed quickly. "Verify, verify and confirm," says Matessino. After all, staff members' lives are on the line, and they have a right to accurate information.

Judgment trumps policy. Frankly, I don't remember which storm veteran said this; I hope he or she will forgive me. The point is that if you have competent, experienced staff, let them do what they need to do. If their best judgment tells them that standing policy is not workable, so be it. We are living and working in an era when some of the calamities we have experienced were not readily foreseeable--indeed, some have been unimaginable--and thus we need to be able to think on our feet. If you can trust your managers and staff under ordinary circumstances, you should be able to trust them in extreme circumstances.

Good security is essential. The last thing the beleaguered staff at Charity Hospital of New Orleans needed in the days after Katrina was to be held up at gunpoint by thugs demanding narcotics from the pharmacy, but that's what happened. Although good deeds are far more common than evil ones in an emergency, the latter still are committed. Local law enforcement or National Guard personnel may not be able to provide protection, so the safety of patients and staff alike may be threatened. Furthermore, if a facility must be evacuated, it would be nice to be able to come back and not find it stripped of its contents. Sexton made it a priority that the entire hospital campus be secured and locked down after the evacuation, and no harm came to it.

Are there sufficient resources for patients, staff, families and pets? The concept of just-in-time inventory has saved a great deal of money for providers, but perhaps we should rethink it in the face of recent experience. Last year's disasters have taught us that:

Remember mental as well as physical health needs. After disasters, we are quite good at taking care of physical needs. We have not been so good, historically, at attending to the psychological needs of people who have witnessed what no one should have to see. Post-traumatic stress disorder is as real for disaster victims and those who care for them as it is for our brethren in the military. We need to remember that seeing your grandmother drown, or being ripped away from your home and plopped into a trailer a thousand miles from where your family lived for 200 years are not dismissible events.

Have a practiced doomsday scenario. No one expected terrorists to run commercial airliners into occupied buildings. No one expected a major American city to go under water. No one knows when the San Andreas Fault may shudder and devastate Northern California. No one knows when any of the volcanoes in the Pacific Northwest might decide to blow. No one can accurately predict tsunamis, which can hit any coast. We tend to plan for what can be reasonably expected--earthquakes in California, floods in the Midwest, tornadoes in Texas, storms in the Gulf. But the strongest earthquake in U.S. history occurred in Missouri, our deadliest flood was in Galveston and tornadoes are more common in Florida than in Oklahoma. It wouldn't be a bad idea, at your next board retreat or managers' meeting, to discuss what you would do if the totally unexpected happened. Because these days, it just might.

My thanks to Leslie D. Hirsch, president and CEO of Touro Infirmary in New Orleans; Teri Fontenot; John Matessino; Robert Pascasio, CEO of Bayside Community Hospital in Anahuac, Texas; Karen Sexton; the other health care professionals whose wisdom I have absorbed over the past year; and all those I interviewed in 1994.

Thanks also to Mary Walker and Texas Healthcare Trustees, Sheila Kizer and Executive Women in Health Care, and Premier for inviting me to their conferences, where I learned these important lessons.

And don't forget the thousands of displaced hospital workers on the Gulf Coast who still need your help. Please donate to www.thecarefund.net. Thank you.

First published in Hospitals & Health Networks OnLine, August 1, 2006

Emily Friedman 2006

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