Disaster Preparedness: Hospitals Confront the Challenge
By Susan Meyers
Lessons Learned from Oklahoma City and Manhattan Provide National Guidance
Responding to heightened awareness of the health care challenges posed by the massive natural disasters and terrorism attacks of the last few years, hospitals nationwide are sharpening their disaster preparedness planning and infrastructure. Events ranging from 9/11 and the Oklahoma City bombing to tornadoes and large-scale hurricanes have many hospitals reevaluating their own preparedness and boosting resources to new levels rarely considered before.
“As members of a not-for-profit hospital board, we represent the community, and we will be held accountable in the event of a disaster,” says Karen Luke, board member of St. Anthony/SSM Health Care of Oklahoma, Oklahoma City. “Therefore, it is our responsibility to ensure that our hospitals have a plan, the resources and the budget to be prepared. This needs to be a priority and, in some cases, may have to take precedence over other areas when it comes down to budget allocation.”
As an example, recent hurricane response efforts have exposed hospitals’ inadequate surge capacities, as well as deficient communications strategies to integrate community resources between hospitals and other community response agencies.
“After the recent hurricanes, we realized a need to refocus hospital efforts on a more coordinated system response,” says Melissa Sanders, branch chief for the Health Resources and Services Administration (HRSA) National Bioterrorism Hospital Preparedness Program (NBHPP). “In a disaster situation, hospitals don’t respond in and of themselves. It becomes a community effort. The fiscal year 2006 refocusing efforts will bring systems response capabilities into a more coordinated focus.”
HRSA is working to refine U.S. Department of Health & Human Services (HHS) “tiered systems response” plan guidelines introduced in August 2004. The guidelines outline a tiered and coordinated system of response capabilities for hospitals that includes collaboration with other local hospitals, community response agencies and public health departments within their communities and across states.
HRSA NBHPP also has a new strategy to address medical surge capability. Developed in collaboration with the Department of Homeland Security, Sanders says the strategy covers five key elements: personnel, including the Emergency System for Advance Registration of Volunteer Health Professionals volunteers (ESAR-VHP); planning, including mass fatality and evacuation plans; equipment and systems, which covers patient movement, bed tracking, mobile medical facilities, decontamination and isolation; competency-based training; and a system of exercises, evaluations and corrective actions.
Sanders says she expects the additional guidelines and mandates to be introduced in May 2006. HRSA initially distributed funds to each state in 2002 to use toward emergency bioterrorism preparedness and for countering terrorism threats. States are now eligible for additional funding to continue their preparedness efforts and to make local allocations.
Help and guidance for disaster strategies is coming from other sources as well. The American Society for Healthcare Risk Management (ASHRM) has partnered with the Association for Healthcare Resource and Materials Management (AHRMM) and the American Health Lawyers Association (AHLA) to provide an audio conference featuring a panel of experts who have dealt with recent disasters to discuss regulatory requirements, disaster planning and real-life challenges. [The audio conference is scheduled for Feb. 28, 2006, from 2 p.m. to 3:30 p.m. EST and requires registration by calling (800) 775-7654.]
“The discussion will focus on mobilization of supplies and resources, coordination with community agencies and resources, risk management, materials management, command and control center systems and regulatory accreditation requirements,” says Elizabeth Summy, executive director of ASHRM.
While federal funds for disaster preparedness have helped hospitals offset some of the initial costs incurred in preparing for bioterrorism threats and improving community response systems, these same hospitals are also finding that they must turn to other sources to maintain funding for this high level of readiness. This includes financial support for operating expenses, disaster training, drills, staff time, equipment and expanded emergency departments and trauma centers. However, in light of recent events, many hospitals have concluded that disaster preparedness is now a necessary component of doing business in today’s health care environment.
Hospitals such as Saint Vincent Catholic Medical Centers, New York City, which received more than 800 patients from the 9/11 terrorist attack on the World Trade Center, and St. Anthony/SSM, Oklahoma City, which treated 500 victims injured in the bombing of the Alfred P. Murrah Federal Building, have learned firsthand how to improve their own disaster responses—and they have become models for other hospitals looking to bolster hospital preparedness.
Manhattan’s St. Vincent’s Hospital has a history of dealing with disasters “all the way back to the sinking of the Titanic,” says Mark Ackermann, the hospital’s chief corporate services officer. “But we never imagined we would ever have to prepare for the magnitude of patients that poured into our hospital after 9/11.” In all, 7,316 patients received care at that time at 108 hospitals in New York, New Jersey and Connecticut, with St. Vincent’s, the closest Level 1 trauma center, treating the most.
Communications
Communication among local hospitals, emergency medical services (EMS) response teams, public health agencies, police and governmental offices is crucial in a disaster, Ackermann notes. During 9/11, New York City’s emergency command center played a key role in updating St. Vincent’s officials and coordinating EMS personnel and other resources.
Since 9/11, Ackermann says the Greater New York Hospital Association has taken tremendous steps to improve disaster readiness and communication among its hospitals and other key health agencies and city offices. Each hospital now has a representative at the central command center who acts as the chief liaison between that facility and the command center. The command center also has a direct line to the mayor’s office. A series of redundant communication systems have been put into place—land lines, cellular phones, computers and 800 megahertz radios—to guarantee communication and a free flow of information throughout the course of a disaster.
A “syndromic” surveillance system has also been created, which records and sends each new hospital admission and diagnosis in the city to the New York City Department of Health to help monitor health trends or epidemics. St. Vincent’s also recently established a Web site listing the names and birth dates of patients currently in the hospital system, designed to help patients’ family and friends find out which hospital he or she is in, as well as providing directions to get there. That system model was used during the recent Katrina/Rita evacuation and proved quite helpful. Oklahoma City plans to model the system and anticipates having it in place by the end of 2006.
That same need for communication created many challenges for hospitals immediately after the Oklahoma City bombing. “Hospitals were working in silos,” says Marla Peixotto-Smith, R.N., director of Emergency and Outpatient Services and Transportation at St. Anthony/SSM. “There was limited communication among facilities, so there was little information about who had what resources available.” To improve communication in the future, the hospitals formed an agreement called the Mutual Memorandum of Understanding, in which they agree to share resources, personnel and time with the neediest of hospitals.
Enhancing Emergency Operations Centers
In 1999, the U.S. Department of Health & Human Services provided funding to 120 of the largest cities in the country to establish Metropolitan Medical Response Systems (MMRS), a structure whose purpose is to provide an avenue for communities to collaborate, plan and improve citywide disaster response.
Triggered by the bombing and a subsequent tornado that caused massive casualties, Oklahoma’s MMRS was one of the first to form a Medical Emergency Response Center (MERC), a facility staffed by hospital personnel and other local response agencies to serve as a centralized medical decision unit that allows for maximum use of hospital resources through heightened communication, coordination and collaboration.
“Almost every major city has some sort of emergency operations center,” says Michael Murphy, director of the Metropolitan Medical Response System, which formed MERC. “However, the typical emergency operations center has little or no hospital representation. As a community, we realized the important role that hospitals play in providing a continuum of care during a disaster situation.”
The development of the Oklahoma MERC was not without its challenges. “There has definitely been a learning curve and cultural change in transforming a typically competitive health care environment to one of cooperation and support,” Murphy says. “But it could not have happened without the support of hospital CEOs and boards. Their support is worth its weight in gold. Boards tend to empower the CEO with the resources they need to put the plans in place. The CEOs were critical in legitimizing our efforts and getting the rest of the hospital staff behind it.”
According to Luke, the federal building bombing in 1995 has helped the health care community and the community as a whole reach common goals of cooperation and community safety. “As a city, we are much stronger today,” she says. “We found that each of us can make a difference, and that our efforts can have a much larger impact when we work together.”
Disaster Drills
Preparing for disasters is a daunting task, as unique issues must be considered for each type of event. For example, the challenges posed by a biothreat are entirely different from those of a chemical disaster or from a natural disaster such as a hurricane or tornado. Today, many communities perform communitywide disaster drills and training exercises involving hospitals, and public and city entities to test their level of preparedness. The JCAHO requires hospitals to test their emergency plan twice a year, including at least one communitywide drill.
Oklahoma’s MERC performs citywide disaster training drills twice a year using a variety of disaster scenarios. The drills are designed to help identify problems with incident command, communications, triage, patient flow, security and other issues.
“Disaster drills need to be taken very seriously,” says Diane Fulton, R.N., M.S., director of Integrated Nursing Practice at St. Anthony/SSM. “We consider disaster drills key to gauging our readiness. The better you perform on a drill, the better you will perform in a real disaster event.”
After each drill, the hospital and participating organizations critique their responses and discuss ways to improve. A report is then sent to each hospital’s CEO and board. Administrators and boards also receive a quarterly “dashboard of gauges” to illustrate a hospital’s level of readiness, Fulton notes.
Flexibility is key in any disaster plan. “Your plan needs to accommodate all types of disasters, during all times of the day and involving all kinds of injuries and numbers of people,” Fulton says. “Since the formation of the MERC, hospitals in the area have invested a lot of time redefining their organizational structures to provide a coordinated effort between hospitals.”
Collaborating on Clinical Care
Dealing with multiple casualties that could potentially overwhelm a facility in a matter of hours requires organization and advance planning. Oklahoma City hospitals have devised a standardized patient documentation system that quickly identifies and easily tracks inpatients and outpatients. Triage guidelines, including a color-coding system for patients, have also been adopted to ensure consistency among hospitals. Additionally, hospitals should have a system in place that assigns staff to 12-hour shifts to make the most efficient use of medical personnel, notes Fulton.
Not only will hospitals in the heart of the disaster have to deal with a mass influx of patients, they will also find themselves inundated with family members and volunteers, who present their own challenges. After 9/11, crowds of close to 25,000 people swarmed St. Vincent’s Hospital, forcing it to turn a nearby university student center into a family center.
Behavioral health counseling was also extended to St. Vincent’s own employees and patients. “We found that 62 percent of ED nurses had significant others who were involved in rescue efforts during 9/11,” says Ackermann. “As each shift ended, we had teams of counselors on hand to provide counseling and support.” And shortly after 9/11, the World Trade Healing Services was established to provide post-traumatic stress disorder counseling to victims and family members.
Hospitals Boost Expansion Efforts
Hospitals such as St. Anthony/SSM and St. Vincent’s have embarked on ambitious ED and trauma center expansion projects to address “surge capacity” needs during disasters, as well as building decontamination facilities for victims of a biological or chemical event. St. Vincent’s three-year, $30 million project will double the size of its ED, allowing the hospital to quadruple its surge capacity and modernize its clinical resources, including adding cardiac monitoring equipment at each bedside and a dedicated CT scanner designed to expedite throughput of ED patients. Additionally, its new decontamination facility will accommodate 200 individuals per hour, built with enhanced security and an improved infrastructure in mind.
“The facility is being constructed with enhanced features to withstand possible terrorist attacks,” says Ackermann. Improved security means fewer exits and access control systems. “We have spent [many] millions of dollars over the last four years training personnel and making major capital improvements, of which about several hundred thousand have come from the federal government,” Ackermann says. The key to the hospital’s efforts has been the board’s unqualified support. “They have supported us in providing millions of dollars in disaster preparedness training and drills at all of our facilities.”
“The board of Saint Vincent Catholic Medical Centers believes very strongly in providing our employees with the training and equipment necessary to face another disaster,” says Alfred E. Smith IV, hospital board member and chair of the system’s foundation. “It is just common sense. Within the foundation, we are embarking on a $30 million capital campaign to renovate and expand the Rudolph W. Giuliani Trauma Center at St. Vincent’s Hospital Manhattan to ensure that New Yorkers have a state-of-the-art facility in the event of a natural or man-made disaster.”
Meanwhile, hospitals such as the Nebraska Medical Center in Omaha, have focused on preparing for an infectious disease outbreak. The medical center has partnered with state and federal agencies to transform a section of its hospital into a state-of-the-art biocontainment unit for infectious diseases.
The 10-bed, $1 million unit—three-fourths of which was funded by the Health & Human Services’ National Bioterrorism Hospital Preparedness Program—is the largest in the country. The floor plan includes decontamination units equipped with showers, air filtering systems, personal protective gear, biohazard suits and pharmaceuticals to treat various biological and chemical agents. Budgeting for operating expenses, salaries and training of 30 to 40 nurses is estimated to cost $165,000 or more a year and falls on the shoulders of the Nebraska Medical Center.
“Our administration has made a commitment to this,” says Pat Lenaghan, director of the biocontainment unit at the medical center. “We are a major referral center for Nebraska, and with the rise of infectious diseases, we feel it’s not a matter of if we’re going to need a facility like this to treat an infectious disease outbreak, but when.”
?The University of Nebraska Medical Center has also created a medical database that identifies about 35,000 health care professionals throughout the state. The database will be used to contact medical workers quickly during major public health events and is a model for the Centers for Disease Control and Prevention as well as a host of states looking to replicate it.
“Recent events have shown us that terrorism threats and large disasters are very real…,” Luke says. “A hospital’s level of preparedness can have a significant impact on a community’s ability to respond and save lives.”
Susan Meyers is a writer based in Omaha, Neb.
This article 1st appeared in the December 2099 issue of Trustee Magazine.
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