Significant changes in hospital emergency planning have taken place since and largely because of Hurricane Katrina in 2005. Hospitals, along with nursing homes, have had their safety and security requirements strengthened by regulatory and/or accreditation agencies to ensure that their emergency plans take into account how they will carry out full or partial evacuations. However, many of these requirements post goals that hospitals have tried to meet only to find out, usually in an emergency, that the changes instituted are still not enough. This year, though, the healthcare community experienced many new emergency situations that challenged not only hospital officials but also community leaders responsible for supporting healthcare institutions during an emergency situation.
Two very different types of emergencies – Hurricane Irene and the Joplin Tornado – that hospitals experienced earlier his year were weather events: one was a sudden and extremely violent emergency lasting only a few seconds that left a major healthcare institution devastated by its effects; the other was a much slower moving event that allowed a planned evacuation for an impending hurricane that would cause major disruptions in several hospitals within the same major metropolitan area.
Both events revealed, once again: (a) how important preparedness planning is for hospitals and other healthcare facilities; and (b) that the planning that had occurred was well worth the efforts made by the communities involved to protect their infrastructures. Both emergency events also revealed a number of flaws and weaknesses in the planning process for hospital evacuations. Following are some of the particulars, including the major lessons learned, about each of those two events.
The Joplin Tornado: Deaths, Destruction & Preventable Delays
Within seconds after touching down in Joplin, Missouri, an EF-5 tornado cut a path of destruction through it that included a hospital – the St. John’s Regional Medical Center – that took a direct hit to its west facade. It took the tornado only 45 seconds to turn the hospital into an unsafe structure. Within minutes it was clear to staff that the hospital was no longer viable for patient care and that a full evacuation would be necessary. In the overall Joplin area, officials later determined, there were an estimated 160 deaths, 8,000 houses, office buildings, and other structures heavily damaged (many of them beyond repair), as well as 18,000 vehicles destroyed. The staff at St. John’s evacuated 183 patients – including 24 patients from the emergency department (which was completely destroyed), 28 critical-care patients, one OR (operating room) patient, and one PACU (post-anesthesia care unit) patient.
Initial Impact: The immediate disaster response was hampered because the hospital’s command center(s) were inoperable, the hospital’s emergency equipment trailers were blown blocks away and destroyed, the hospital’s MedEvac helicopter – and the landing pad at the hospital – also were destroyed, and only a very few of the hospital’s emergency plans could be accessed during the evacuation. In addition, the hospital’s emergency generators failed to start – but that problem proved to be a blessing, because the hospital also had experienced a gas leak that might otherwise have caused an explosion.
Evacuations: Evacuation sleds were available to the rescuers (hospital staff mostly), but there were not nearly enough sleds to evacuate patients down nine floors of unlighted stairs littered with debris. For that reason, doors, wheel chairs, and mattresses were used to evacuate patients to pre-planned evacuation points. Most of the patients were transported – to the closest area hospitals still functioning – in POVs (privately owned vehicles, including pickup trucks), some of which were carrying hospital beds, with hospital staff riding in back holding IV tubes.
The healthcare after-action report described the evacuation as “impossible”; nonetheless, all patients were eventually evacuated to the staging areas that had been set up outside the St. John’s area (senior officials later credited drills and training for the effectiveness of the overall evacuation process). The patients evacuated were then taken from the staging area to other hospitals by POVs, ambulances, and MedEvac, with the last patients arriving by the following morning. Meanwhile, a number of tents served as temporary-care areas to treat the injured as the days went by.
Patient Tracking: Because of the emergent nature of the tornado – combined with the almost total devastation not only of the hospital infrastructure but also numerous caches of emergency supplies – the tracking of patients was a true “nightmare,” according to the on-scene responders. The same officials later estimated that it took them over four days to completely account for all patients; they also pointed out, though, that the availability of electronic medical records represented a major improvement in the evacuation progress because up to two years of medical records of all of the patients evacuated could be accessed online.
The Fictitious “96 Hour Supply”: Hospital officials identified the theoretical “96-hour supply” (of medicines and medical equipment) as a significant weakness in planning because most if not quite all of those supplies were used up in about four hours. The same officials confirmed, in their after-action report, the need for much larger caches for the same length of time (96 hours). They also suggested that those much larger caches should be stored in safer positions – bunkers, perhaps, that are much better protected from danger – so that they could be accessed much more quickly after a major emergency.
MOUs and other suggestions: The hospital and emergency managers also suggested that such equipment items as “go-bags” on patient units and staff identification tags be carried in wallets, because many of the standard hospital tags were lost during the hurricane. Memorandums of Understanding (MOUs) for equipment suppliers and ambulance services were found to be another positive, despite the fact that they were not much help in the immediate aftermath of the tornado. There also is a compelling need, the same officials said, to practice – better and more frequently – what the hospital staff must do if the supply system is overwhelmed.
Hurricane Irene: Major Problems Cited, Major Changes Underway
Hurricane Irene struck the New York Metropolitan area with a near-knockout punch in the late evening of 27 August, and continued the assault for quite a few hours thereafter. Although it did not hit with the force originally predicted, it caused flooding in many areas of the city as well as wind damage and other storm effects that disrupted everyday life in the nation’s most populated city for over a week. The planning for the hurricane started several days earlier and – thanks in large part to the fact that many U.S. cities have dealt with major hurricanes in the past – the plans for hospital and nursing home evacuations had been put in place early by various political jurisdictions along the Atlantic coast, and specifically in many areas of New York City itself.
SLOSH Zones & Training Drills: Since the hurricanes of 2005, New York City’s hurricane planning has involved hospitals and nursing homes in the city’s “SLOSH” coastal and low lying shore or river areas – SLOSH stands for Sea-Land-and Overland-Surges-from Hurricane Zones – that probably would be affected either by flooding or by the winds generated by a large coastal storm. Storm models, hospital preparedness plans, and training drills – carried out by both city and state preparedness agencies – have been enhanced and significantly improved over the past five years. The hospitals and/or nursing homes potentially affected knew that they had to have the plans ready and at hand, ahead of time, on how they would evacuate or shelter in place to deal with the most severe effects of a storm such as Irene.
Hospital Evacuations: For what was probably the first time in the city’s history a declared emergency was called prior to the storm’s arrival; the emergency plans required the mandatory evacuation of numerous hospitals and nursing homes throughout a significant area of the city. Most hospitals started their evacuations days before Irene’s arrival – and continued, in reverse, when they later had to relocate the same patients back to the same hospitals several days later (after the worst of the storm effects had ended).
MOUs and EMS Support: Many of the city’s hospitals rely on the same limited number of MOUs (memoranda of understanding) for patient transport. The city’s emergency management system (EMS) is operated by the city’s fire department – FDNY (Fire Department of New York) – which usually carries out only “911-emergency” types of transports – and was made available for patient transfers to other hospitals within the city. The private ambulances that hospitals had available to them, thanks to the MOUs, also were used – but, as would be and was expected, most of the hospitals directly affected had to reach out, through the same or other mutual-aid agreements, for additional units.
Patient Transfers and Tracking: The city’s plan did address the support of ambulances to the many institutions directly affected, but the patient-by-patient transfers were left, for the most part, to the individual hospitals to arrange. In short, this extraordinarily large institutional evacuation was not only extremely complicated but also required hospital-to-hospital communications that went well beyond the previous day-to-day transfer experience of most of the hospitals participating. It also was not a routine movement of patients that the city’s OEM (Office of Emergency Management) was fully prepared to carry out. The overall number of transfers was extremely large and impressively coordinated (as were the return transports after the storm had passed). Despite that hugely successful effort, though, many hospitals experienced being “on their own” in many ways that they had not expected, or previously experienced.
The Major Lessons Learned: Although the Joplin tornado and Hurricane Irene occurred several months ago, many of the lessons learned are still being reviewed, and it probably will take at least several months more before those hard-earned lessons are incorporated into actual changes in emergency procedures and preparedness planning. Additional after-action reports, corrective action plans, and future emergency drills will still be needed, and must be heeded, to truly improve hospital emergency responses throughout the two metropolitan areas hardest hit – and in other jurisdictions throughout the United States and U.S. territories. The fact that hospitals can clearly see the value of needing plans that make it possible to respond, quickly and effectively, to weather events that might require partial and/or total evacuations – in time frames lasting anywhere from a few minutes up to several days – is perhaps the most important lesson learned this year by hospitals and municipalities throughout the country.
Theodore “Ted” Tully is the Administrative Director for Emergency Preparedness at Mount Sinai Medical Center in New York City. He previously served as Vice President for Emergency Services at the Westchester Medical Center (WMC), as Westchester County EMS (emergency medical services) Coordinator, and as a police paramedic/detective in Greenburgh, N.Y. He also helped create the WMC Regional Resource Center, which is responsible for coordinating the emergency plans of 32 hospitals in lower New York State.