The New Normal? 7 Ways Bigger Hurricanes Could Test Health Care Emergency Preparedness
November 13, 2018
"When you have two 500-year floods within two years of each other, it's pretty clear it's not a 500-year flood."
- North Carolina Governor Roy Cooper at a news conference in the aftermath of Hurricane Florence
Scientists from the National Center for Atmospheric Research agree with that sentiment. The research article they co-authored notes that “the resulting environment, including higher ocean heat content and sea surface temperatures invigorates tropical cyclones to make them more intense, bigger, and longer lasting and greatly increases their flooding rains.” The U.S. Global Change Research Program has reached the same conclusion.
PwC’s Health Research Institute puts numbers to the devastation caused, advising that natural disasters cost the U.S. $195.2 billion during 2017—more than a five-fold increase from the previous year. Hurricanes Harvey, Irma, and Maria accounted for much of that increase.
What does the emerging new normal of weather-driven natural disasters mean for the hospital and health care community?
Case history: Lessons learned from Hurricane Harvey
Two days after Hurricane Harvey made landfall on the Gulf Coast, we were in South Texas. For the next seven days, we provided incident command support and assisted with longer-term recovery plans for a health system division consisting of 17 hospitals located in areas affected by the record-breaking Category 4 hurricane.
Our after-action analysis, along with that documented by the Texas Hospital Association and the Federal Emergency Management Agency (FEMA), provides seven important insights into how Harvey and the entire 2017 hurricane season tested response capacities.
- Availability and medical readiness of shelters. Harvey morphed very quickly into a massive storm. According to the Texas Hospital Association, this rapid chain of events gave residents and others just 50 hours to prepare, instead of the usual five to seven days.
Without enough shelters open to accommodate the 40,000 people who left their homes, hospitals became defacto shelter and evacuee sites. The resulting influx of evacuees further taxed hospital resources and staff as they worked to care for patients during a catastrophic weather event.
Our experience: In the health system division we supported, hospitals sheltered large number of people. At many of these hospitals, half of those temporarily living on site were patients and staff—the other half were evacuees.
Corporate had cached food, water, medical supplies, and other resources prior to the storm. By assisting with the assessment, identification, and prioritization of needs, we were able to help prevent potential shortages from disrupting hospital operations.
Lessons learned: Based on their all-hazards risk assessments, hospitals should consider whether disasters could press them into service as shelters. Should this possibility be part of disaster preparedness planning?
- Stabilization of critical infrastructure. FEMA’s after-action report repeatedly emphasized the need for coordination among 16 sectors, identified by Homeland Security as critical infrastructure, to maintain a foundation for effective response and recovery.
According to the Texas Hospital Association, the main infrastructure challenges during Harvey included:
- Problems maintaining a timely, accurate flow of information with state and federal government agencies, military responders, local police departments, and the media
- Difficulties transferring medically fragile patients due to flooding and damage to the transportation infrastructure
- Strains on hospital staff and clinical resources when dialysis centers, federally qualified health centers, and other facilities closed—and their patients turned to hospitals for care
Our experience: Transportation problems made it difficult to get relief to hospitals where staff had been overnighting for days, working shifts of 12 hours or more.
Implementing a “staff swap” was one of our first jobs. Air transport was the only option, but that system was compromised and overtaxed. Using heavy lift helicopters and working with federal contacts to get the necessary flight clearances, we assisted the health system in delivering relief staff onsite within five hours of our arrival.
Lessons learned: Hospitals may want to consider how transportation challenges during an extended disaster could require staff to overnight and work long hours for days, unable to check on homes, families, neighbors, or pets.
Do preparedness plans accommodate this scenario? What if hospitals need to bring in large numbers of relief staff from outside the affected region?
- Effective, efficient communications. The Texas Hospital Association identified significant breakdowns in communication, one of the 16 critical infrastructure sectors. Disconnects complicated response and recovery.
Problems resulting from poor communication included:
- Misallocation of resources by state and federal agencies
- Evacuees, some injured, helicoptered in by the military—without warning—to hospitals
- Inconsistent and inaccurate public messaging about curfews, impeding the ability of staff to report to work
Our experience: We used the health system’s enterprise-wide, web-based system to communicate efficiently, in near real-time, with hospitals in the division, leaders at corporate, and other divisions in the health system.
Unfortunately, our assessment of the flow of information outside of the health system mirrors the findings of the Texas Hospital Association. Communication gaps posed challenges as we worked to develop situational awareness.
In some cases, we used our relationships with state and federal colleagues, built over years of working together, to facilitate communication and gain the information we needed.
Lessons learned: The flow of information can make or break response and recovery. Hospitals and health systems should carefully assess this aspect of their preparedness plans and work with health care coalitions, government agencies, and other partners to address any shortcomings.
“We proved ourselves within the first ten minutes of arrival at incident command. Within 30 minutes, we were executing the division plan to relieve ‘first wave” staff,’ getting them back to their families.”
- Mark Ross, Vice President, Emergency Preparedness, The Hospital and Healthsystem Association of Pennsylvania
- Staff resiliency—including incident command. Catastrophic, week-long events like Harvey take their toll on staff, who may be separated from families and worried about their health, comfort, and safety.
Our experience: Hurricane Harvey affected 40 percent of staff and their families in the division we supported. Implementing leadership’s action plan to relieve staff, including incident command, was our top priority.
Leadership’s trust in our team’s collective knowledge and experience allowed us to provide support in many areas. As a result, system and division leaders were able to focus on recovery strategies, including:
- Getting employees the resources and assistance, including housing, they needed
- Orchestrating the return to normal operations in measured, sustainable phases designed to meet the most immediate needs of communities ravaged by the storm
Lessons learned: Hospitals should think about how week-long disasters could overextend leadership and incident command as well as staff. Do plans to support staff also consider the needs of leadership?
- Supply chain resiliency. According to Texas Hospital Association, hospitals typically secure 3–4 days of “ride-out provisions” when preparing for hurricanes. During Harvey’s unprecedented rainfall, hospitals, serving as shelters as well as care providers, found that they needed 5–7 days of provisions.
Infrastructure challenges, especially in communications and transportation, stressed hospital supply chains.
Our experience: As part of a large health system, the 17 hospitals we supported had access to adequate supplies and the communication and transportation infrastructure needed to deploy them. As a result, division hospitals were able to maintain operations as well as share with other facilities outside the health system.
When Harvey shifted east, and yet another facility needed to be evacuated, we supported logistics and tracking around the transfer of patients to available beds in “our” health system.
Lesson learned: Sharing available resources among affected hospitals and other health care facilities, to help keep them operational, can save lives. Hospitals should have mutual aid agreements with others in the region and state and the means to support one another during disasters.
- Availability of adequate security. The Texas Hospital Association identified security as a major concern for the hospital community during Harvey. Hospitals that relied on off-duty police officers for security were especially challenged.
Our experience: Once again, the health system’s corporate leaders were able to redirect resources to the division affected by the storm. Following a pre-incident preparedness checklist, the system stationed security officers at every facility. Officers staffed all facilities, even those closed for the storm.
Lessons learned: Hospitals may need extra security during disasters. Do disaster plans take this into account?
- Effective use of volunteers. The massive influx of health care volunteers and supplies created logistical problems for hospitals. Hospitals had to check manually the credentials of volunteer clinicians who were licensed out of state.
Our experience: Effective use of incoming volunteers and donations can, in the short term, have the unintended consequence of putting additional pressure on those directing the response.
On the other hand, turning able-bodied people displaced by a disaster into volunteers can assist the response in important ways.
For example: at one hospital, evacuees temporarily living there took charge of caring for pets that were also in residence.
Lessons learned: Credentialing out-of-state medical volunteers has been an issue at every disaster we’ve worked. We need a national approach to support the quick processing of volunteers seeking to contribute to health care surge operations.
Promoting a calm, respectful environment is important during any disaster. Hospitals should look for ways to attend to the emotional health and well-being of patients and staff and their families and others.
On-demand, on-location support in just 16 hours
HAPevolve—the HAP subsidiary that ultimately deployed us as consultants to assist with Harvey—received the initial call shortly after the hurricane made landfall.
The health system, and its hard-hit South Texas division, had prepared well. But the catastrophic nature of the storm, geographic reach, and significant displacement of people pressured health system resources and stretched personnel.
Was extra support up to the task and available to step in? If so, the health system was interested.
Within 16 hours, our team of three was on location. Within 36 hours, we were supporting incident commanders to the extent that there were able to focus on developing plans to support the longer-term needs of patients, staff, and communities.
As we packed up to leave, division leaders commented that “we only wish we had asked earlier, so you would have gotten here even sooner.”
Is health care ready for the new normal? We’d like to help make sure.
The practice of disaster preparedness and response has achieved impressive progress during the past few decades. We know that many hospitals and health systems are more prepared than ever.
We share this summary of our experience with Hurricane Harvey to support the continuation of this progress. Now, more than ever, disaster preparedness plans must be resilient, flexible, and adaptable to current, emerging, and future threats.
In that spirit, we are pleased to offer an initial review of existing health care disaster preparedness plans, including those from long-term care and assisted living facilities as well as hospitals and health systems.
About the authors
As leaders of The Hospital and Healthsystem Association of Pennsylvania (HAP) emergency preparedness team, Tom Grace and Mark Ross have worked together for more than a decade. They supported and coordinated the Pennsylvania hospital and health care response for public health epidemics as well as man-made and natural disasters, including:
- Hurricane Irene (2011)
- Tropical Storm Lee (2011)
- Hurricane Sandy (2012)
As part of HAP’s consulting subsidiary, HAPevolve, they supported the hospital and health care response to:
- Hurricane Irma (2017)
- Hurricane Harvey (2017)
- Hurricane Florence (2018)
- Hurricane Michael (2018)
Grace and Ross have also coordinated health care preparedness and response for large-scale events (the 2015 Papal Visit to Philadelphia), public health emergencies in Pennsylvania (H1N1 and Ebola), and man-made disasters (the Amtrak 188t train derailment in Philadelphia).