NYU’s incident command center
during Hurricane Sandy

Special report: Planning for the unlikely

August 28, 2013
by Carol Ko, Staff Writer
In the last year or so, it seems the nation’s hospitals were besieged by a variety of high-profile disasters, including Hurricanes Irene and Sandy and the Boston Marathon bombing. These events get at the primary challenge of emergency preparedness: trying to anticipate and prepare for the unknown.

Preparing for disasters is always a tricky balancing act — departments are often caught in the difficult position of being considered a resource drain when things are going smoothly, only to be raked over the coals when a disaster catches a hospital unprepared. They’re often required to stretch a limited (and shrinking) budget against a series of worst-case scenarios which they hope will never happen.

The art of risk management, in short, is always a gamble. Even the most well-intentioned plans to anticipate realistic natural disasters and risks can fall victim to unpredictability. For instance, in 2005 scientists determined there is a 90 percent probability of a 6 to 7 magnitude earthquake in the Chicago metropolitan area in the next 50 years — a contingency that hospitals in the area had to account for going forward. “If you asked me ten years ago about earthquake preparedness in Illinois, I’d say it was not on our list. Who would have thought we’d have earthquakes?” says George Mills, department director of the engineering department at The Joint Commission.

Still, planning for the worst requires planning for more than just looming earthquake threats. Hospitals are trying to push their doomsday scenario drills as far as they can. Though NYU has always had a robust exercise program, including multiple evacuation exercises that stretch from the unit all the way to the street, in the aftermath of Hurricane Sandy director of emergency management Kristin Stevens realized that these exercises needed to be escalated even further.

“There has been so much that surprised so many people across the city that I think when we’re planning exercises, you want to keep it realistic but stretch it as far as you can go get people to think about things they would consider unlikely to happen but are still possible in some capacity,” she says.

To guard against future hurricanes, NYU is building an exterior barrier system, made up of permanent and temporary barriers, to protect the perimeter of the medical Center’s main campus. Additional interior barriers are now being installed, designed to prevent the spread of water between buildings or to critical areas on lower levels. “By 2017, the perimeter of the main campus will be protected by walls and gates — both permanent and movable — that will guard against far higher surges than New York City has ever seen,” says Stevens.

During the Boston Marathon bombing on April 15th, hospitals in the area had already been preparing for an emergency situation — they just didn’t know what form that emergency would take.

Because of the size of the marathon crowd, hospitals had already staffed up and developed an emergency plan in case they saw an influx of patients who were dehydrated, exhausted or suffering from race-related injuries.

When the bombing occurred, area facilities were faced with a bigger emergency than they had imagined. But their preparations for a patient surge enabled them to respond quickly and more efficiently to the situation.

Boston’s experience is a prime example of why experts say it’s generally more helpful to plan for capabilities rather than trying to develop emergency exercises around very specific threat scenarios. “There’s a natural tendency to focus on threat scenarios because people are always drawn to the last thing that happens, so they focus on snowstorms or earthquakes because that’s what gets your attention,” says Dr. Paul Biddinger, director of disaster medicine at Massachusetts General Hospital Department of Emergency Medicine. “But there’s no question hospitals have been encouraged to engage in capability-based planning. And the vast majority has tended to move in that direction.”

In fact, medical surge is listed as one of the National Healthcare Preparedness Programs’ eight primary capabilities, which provide the base for all forms of hospital preparedness. “You can’t adjust to every different type of event. What you need to have is foundational processes that apply to all hazards,” says David Marcozzi, director of National Healthcare Preparedness Programs, U.S. Department of Health and Human Services.

Speak easy
Thanks to recent investments in an interoperable communication system, Boston’s emergency medical services agency was able to leverage aid from outside agencies from the greater metro area to save lives during the bombing — of the 250 patients who were admitted to the hospital alive, all survived.

But what’s disturbing about the success of Boston’s response is that it may be a notable exception rather than the norm. In fact, the biggest obstacle to hospital preparedness consistently cited by experts is surprisingly simple: communication.

In the past, EMS response to mass casualty events has commonly been hampered by a lack of communication. For instance, if the community sends all its ambulances to one hospital that’s limited in capacity, that hospital may be overloaded while another nearby hospital that’s available may not be part of the response.

In an ideal world, according to The Joint Commissions’ Mills, the community would create a command center that would direct the flow of patients during an emergency, gathering information from various hospitals about how many beds they have and how many patients they’d be able to take. In reality, the EMS usually has different relationships with different hospitals, resulting in an inefficient distribution of patients during an emergency.

“It’s always tempting for EMS providers to always take their sickest patients to the closest hospital even though self-treating patients will also go and overwhelm it. You need good discipline and good communication to distribute patients across all the available hospitals,” says Biddinger.

Dr. Nick Cagliuso,
Corporate Director Emergency Management,
Continuum Health Partners, (center)

Good communication is also crucial when it comes to dealing with the practical logistics behind disaster management. Most hospitals get their supplies from the same vendors, so when a largescale weather event such as Hurricane Sandy strikes the region, all the hospitals compete for the same resources from the same vendors who now have significant logistics problems to overcome to deliver supplies. “Unless you can access resources by foot, just plan as though it doesn’t exist,” says Nicholas Cagliuso, corporate director of emergency preparedness at Continuum Partners.

In the past, hospitals focused on emergency response as it relates to serving the community — but what if the hospital itself is the site of the emergency, as it was during Hurricane Katrina? “That was a wakeup call for a lot of people,” says NYU’s Stevens.

Within the emergency preparedness field there’s been a push in recent years to think not only in traditional emergency response terms but also to plan around the concept of business continuity—that is, ensuring that systems within the hospital are running when it’s impacted by a catastrophic event.

Stevens cites an example from a few years ago — a steam pipe explosion in midtown, New York blocked access to buildings in the city that provide essential supplies and services. “Events like this bring up the question of how you will you provide those services and care for patients. Emergency management would have focused on [an event like] a fire in your building, but business continuity goes into what to do if you can’t provide your normal services. We’re definitely moving more and more in that direction,” says Stevens.

Such logistical planning requires that hospitals not only have good internal communication, but also good communication with other facilities.

“Health care coalitions started to be and continue to be a big issue for the coming years in hospital preparedness,” says Stevens. Coalitions enable hospitals to pool their resources and coordinate their contingency plans so their emergency response is more comprehensive—especially when it comes to business continuity planning.

Encouragement is also coming from the federal level: the grant funding for the Office of the Assistant Secretary for Preparedness and Response under the U.S. Department of Health and Human Services has become more and more focused on coalition-building, and this guidance is shaping the overall trend in the field. This July, HHS announced that it has awarded $332 million toward hospital preparedness, in part, to help health organizations work collaboratively to maximize resources and prevent duplicate efforts, focusing on what the agency calls “whole community” planning.

Rumor mills
Official internal communication played a large part in Mass General’s successful handling of the Boston Marathon emergency. According to Biddinger, the hospital had purchased an electronic notification system that with a push of a button can notify more than 100 personnel of an event that requires them to spring into action and execute a disaster plan.

Within nine minutes, leadership and specific departments were notified so people could find and prepare beds, mobilize blood banks, and round up teams of surgeons and respiratory therapists. “All of that happened with electronic communications systems we put in place in the last few years,” says Biddinger.

But unofficial channels of communication such as Twitter also played a significant role. “The information gleaned from those websites was helpful or sometimes even more helpful,” says Biddinger. He cites the example of one anesthesiologist in charge of the operating rooms who’d already heard through Twitter that there was an explosion. He quietly prepared the ORs sooner than the hospital would have had it waited for an official notification.

Even so, communication strategies can sometimes struggle to adapt to unexpected scenarios. For instance, during the Boston manhunt, when the entire city was under lockdown, communicating to staff and patients was at times a huge challenge. Part of it was due to the inherent fluctuations in the situation—advisories were changing and shifting every few minutes, and even updates filtering through official channels were often in conflict. To add to the nightmare, people were advised to stay put in their homes or at work.

Such challenges aren’t the norm for weather-related events, which typically give hospitals some advance notice. In the face of such chaos, hospitals have to make measured choices around their business continuity plans. “We need to determine what needs to remain open for patient safety versus the things we can do without over a period of time that doesn’t impact patient safety,” says Barry Wante, director of emergency management at Brigham and Women’s Hospital.

Don’t overlook the small stuff
One of the biggest challenges hospital preparedness professionals face is making sure the lines of communication continue to stay open after the adrenaline rush of the emergency is over.

For instance, NYU’s Stevens cautions hospitals to follow up after every incident and develop action reports for improvement plans. “They’re not lessons learned unless you’ve done something with what you’ve learned,” she says.

Other experts emphasize the importance of capitalizing on each event to raise internal awareness. Small, seemingly insignificant tasks like mass emails, monthly agenda reminders and quick, informal assignments can make a big difference in the end.

“We tend to think of exercises as always big and complex, but one of the things we learned in Sandy is we got a lot of lessons out of the evacuation drills we had done that were much more simple,” says Stevens. For example, she recommends hospitals have their staff walk down their stairwells and acquaint themselves with other units to see what they’re like. Or, have staff walk down nine flights of stairs to see whether it’s doable for them. When the time comes to put emergency plans into action, the staff will have a better handle on the situation simply because they’re more familiar with their surroundings.

“It doesn’t have to be lights and hazmat suits and high maintenance tools only. Plain old awareness can go a long way in helping us as an organization and as individuals better,” says Continuum Partners’ Cagliuso.