For Hospitals Facing Hurricane Season, Preparation and Practice Are Critical
With the heart of hurricane season fast approaching, now is an important time to be prepared. Healthcare organizations that face the potential threat of a hurricane should evaluate current levels of disaster preparedness, potentially update plans, and consider readiness drills.
In August 2017, when Hurricane Harvey struck Texas and parts of Louisiana, the storm unleashed more than 60 inches of rain in some areas of Texas—an unprecedented amount for a tropical cyclone in the United States—causing devastating flooding. At least 68 lives were lost, 24 hospitals evacuated, nearly 780,000 individuals left their homes, and 42,000 people sought temporary housing in 692 shelters as a direct result of the storm. Total damages exceeded $125 billion. a
More Intense Hurricanes in the Future Mean More Hospitals Must Prepare
Hurricane Harvey may be a harbinger of future hurricanes’ ferocity. b Research suggests that although there are fewer hurricanes today than in decades prior, the intensity of storms has significantly increased. One study found that the number of storms rated as Category 4 or 5 doubled over the past 35 years. c A different study by researchers at the Georgia Institute of Technology found a strong correlation between rising sea temperatures and an increase in the occurrence of Category 4 and 5 storms. d Recent research also suggests that in addition to hurricanes becoming stronger, they are also becoming wetter. e As hurricanes become more intense and flooding potentially more widespread, hospitals in locations previously untouched by hurricanes also will need to prepare for potential impact.
Lessons Learned from Past Hurricanes
Past hurricanes serve as constant reminders of the importance of emergency plans and trainings. Lessons learned from prior hurricanes can meaningfully inform preparation for the next storm and help save lives. Hurricane Harvey’s death toll was considerably less than the more than 1,800 people who lost their lives due to Hurricane Katrina in 2005. A September 2014 report by the U.S. Department of Health and Human Services (HHS) evaluating hospitals’ preparedness for Hurricane Sandy, which struck in 2012, notes that 171 of 172 affected hospitals reported that their emergency plans were useful during the storm, and 139 hospitals reported they made changes to their plans following the hurricane. f
In an interview in September 2017, former HHS Secretary Mike Leavitt discussed how lessons learned from Hurricane Katrina improved preparedness for Hurricane Harvey. Secretary Leavitt explained that the ultimate lesson is that “preparedness is everyone’s job and it has to be done in advance.” g Hospitals must prepare, but so must the local, state, and federal government, as well as community organizations and individuals. When possible and appropriate, hospitals should seek to coordinate with government officials and community organizations to ensure mutual preparedness and clear communication.
Although hospitals have written plans in place for disasters, additional resources can help ensure those plans are up-to-date. Hospital CFOs can find a valuable resource in HFMA’s disaster planning checklist. h The topic also was the focus of On Point in November 2017, where the discussion was on how hospitals can revisit their emergency preparedness plans and consider six key areas: leadership, self-sufficiency, staff, finances, reputation, and mental health. i
Four Primary Areas of Consideration
For this month’s On Point, Stewart Simonson, former Assistant Secretary for Public Health Emergency Preparedness at HHS, offers important considerations for hospitals’ hurricane preparedness, identifying four key areas where hospitals could benefit from revising or augmenting their current plans. By no means a comprehensive list, these four areas warrant attention because they offer hospitals some of the best opportunities for continual improvement in their disaster preparedness, effective both during and in the wake of hurricanes.
Across all four areas, checklists are especially important for the disaster plan and its implementation. Checklists can exist for different individuals, different parts or floors of the hospital, and different days before a hurricane’s expected landfall.
Practice is key. No matter how comprehensive and thoughtful a hospital’s disaster plan, that plan is of minimal value unless the hospital drills it at least annually, and it is the responsibility of leadership to ensure these drills occur. The CEO should take the lead, setting the tone for his or her hospital’s disaster preparedness and ensuring that practice remains a priority.
Tabletop exercises can be especially useful in preparing for a hurricane or other natural or man-made disaster, particularly if the CEO runs the exercise. These exercises should detail clear roles for different members of the hospital staff and clear checklists for actions that need to be taken on different floors or in different parts of the hospital. Tabletop exercises can expose blind spots in the plan and assess how well the hospital team works together.
Practice also can provide helpful evidence of the challenges of continuing to provide care to patients during a hurricane. FEMA provides tabletop exercises that the private sector can use not only in preparing for a hurricane, but also in preparing for a cyberattack, communitywide disaster, critical power failure, earthquake, or chemical incident. j
Innovation during a disaster is sometimes necessary, but reliance on and confidence in existing systems is critical. The September 2014 HHS report notes that during Hurricane Sandy, electricity outages compromised relied-upon technology, which required at least one hospital to organize crash courses on providing care without the benefits of technology (e.g., teaching nurses to manually count the number of drips to ensure the IV pumps delivered fluid at the appropriate rate). Clinicians trained before some of the latest advances in technology may have knowledge that is particularly valuable during a hurricane when technology is disabled. Incorporating these types of care delivery backup plans into disaster training drills may help spread valuable knowledge across the hospital staff. Natural or man-made disasters will almost inevitably introduce unexpected challenges that require makeshift—but sound—solutions.
Ideally, most innovation will have occurred before an event. A hospital’s response to a disaster should be as automatic as possible, and implementation should require as little thinking as possible. Checklists should be an essential part of every hospital’s disaster preparedness plan and should be tailored for different individuals and their responsibilities. Atul Gawande—surgeon, writer, and newly appointed CEO of the Amazon, JPMorgan Chase, and Berkshire Hathaway healthcare venture—writes: “Checklists . . . remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification but also instill a kind of discipline of higher performance.” k Checklists, if sufficiently drilled and tested for efficacy, are a reliable way to reduce deficiencies and human errors and are an important component of every hospital’s disaster response plan and practice.
Adjusting hospital ordering based on seasonal needs can help improve preparedness. The Atlantic hurricane season runs from June 1 through November 30. Hospitals may want to consider adjusting their ordering practices and supply chain management to include more inventory during hurricane months. An effective specific tactic may be to routinely place an order for certain materials whenever a hurricane watch is issued. Hospitals in the line of an advancing hurricane may want to assess their blood supplies prior to its landfall and consider increasing supplies of blood and other essential, lifesaving products.
During Hurricanes Sandy and Harvey, non-evacuating hospitals experienced influxes of patients from hospitals that evacuated, of community members with medical needs but non-acute conditions, and of individuals with no medical needs but who could not find shelter anywhere else. This unexpected surge in people requiring medical supplies and/or food taxed these hospitals’ resources. Particularly vulnerable patients, such as those on dialysis, often turned to the hospital for care because their regular dialysis centers were closed during and after the storm and community shelters were not equipped to provide the procedure. Consequently, shortages of dialysate and safe water affected several hospitals. Moreover, the excessive flooding after Hurricane Harvey meant resupplying the hospital in the days following the storm was particularly difficult. l Although a balance must be struck between extra ordering in preparation for a storm and too much ordering of supplies that may spoil or expire and strain hospital resources, ensuring the hospital’s self-sufficiency is critical.
An effective preparedness plan includes clear steps starting 120 hours from the hurricane’s predicted landfall. Hurricanes, unlike other natural or man-made disasters, are detectable days before they make landfall. The National Oceanic and Atmospheric Administration’s National Hurricane Center provides a useful tracking website. m A hurricane watch means that hurricane conditions are possible; a hurricane warning indicates that hurricane conditions (sustained winds of 74 mph or higher) are expected somewhere within a specified area. As the hurricane’s probability is detected, and its landfall becomes more likely, hospitals should take the appropriate preparations. A hospital’s written plan—and subsequent drills—should include detailed checklists of actions to take 120 hours, 96 hours, 72 hours, 48 hours, 24 hours, 12 hours, 6 hours, and 0 hours before impact and then at least 3 to 6 hours after impact.
These checklists should account for both complex and relatively simple considerations. For example, several days before a major hurricane’s expected landfall, it may be wise to reduce the hospital’s census by cancelling elective procedures and transferring certain patients to hospitals out of the flood zone. It is also important 48 hours in advance of a hurricane to ensure portable generators are ready for immediate use, patient care areas are prepped, and flashlights have functioning batteries. Also well in advance of the hurricane’s anticipated landfall, hospitals should move patients and supplies—including generators, if possible—to higher floors that are unlikely to flood. Even one inch of floodwater can disable a generator or compromise other essential goods and equipment. If a hospital’s generators cannot be moved to higher ground, the hospital should consider investing in permanent or portable flood barriers to protect the generators and related infrastructure.
The Essence of Being Prepared
The French scientist Louis Pasteur is often quoted as saying, “Chance favors only the prepared mind.” Applying these words to the field of disaster response, we might well say, “Success favors the prepared mind.” The more thought that goes into a hospital’s disaster plan prior to the event, the more likely it is the plan will succeed when the time comes to implement it. Although every hospital has a written disaster plan, that plan is meaningful only to the extent it has been drilled and then evaluated for lessons learned from these drills. Checklists for different roles and for different actions to take in the days before a hurricane also can reduce costly and avoidable errors. As hurricanes grow in intensity and as the flooding that they cause becomes more widespread, both hospitals situated in well-established hurricane zones and those that are just now beginning to face an unprecedented threat from hurricanes must methodically and diligently prepare.
a. FEMA, “ Historic Disaster Response to Hurricane Harvey in Texas,” Sept. 22, 2017; Blake, E., and Zelinsky, D., “ National Hurricane Center Tropical Cyclone Report: Hurricane Harvey,” National Hurricane Center, May 9, 2018.
b. Fischetti, M., “ New Data: Hurricanes Will Get Worse,” Scientific American, May 16, 2018.
c. Schiermeier, Q., “ Storms Get Fewer but Fiercer,” Nature, Sept. 15, 2005.
d. Hopkin, M., “ Warming Seas Cause Stronger Hurricanes,” Nature, March 16, 2006.
e. Fischetti, M., “ Stronger, Wetter, Slower: How Hurricanes Will Change,” Scientific American, May 30, 2018.
f. Department of Health and Human Services Office of the Inspector General, “ Hospital Emergency Preparedness and Response During Superstorm Sandy,” September 2014.
g. Leavitt, M., “ Michael Leavitt on Hurricane Harvey Health Care Response,” C-Span, Sept. 3, 2017.
h. HFMA. “ Disaster Planning Checklist for Chief Financial Officers of Healthcare Organizations.”
i. Winfield, L., “ In the Wake of Hurricanes, Hospitals Should Revisit Their Emergency Preparedness Plans,” hfm Magazine, November 2017.
j. FEMA, “ Emergency Planning Exercises,” last updated April 13, 2017.
k. Gawande, A., “ The Checklist Manifesto: How to Get Things Right,” Picador, 2011.
l. Texas Hospital Association, “ Texas Hospital Association Releases Special Report on Hospital Disaster Response During Hurricane Harvey,” Feb. 7, 2018.
m. NOAA, National Hurricane Center.