Three health system leaders describe how their organizations stayed on top of situations that left communities reeling.
The day after a gunman killed 49 people and wounded 53 at Orlando’s Pulse Nightclub, Orlando Regional Medical Center received an unexpected delivery of 50 pizzas.
But before weary staff could think about helping themselves to some comfort food, Eric Richard Alberts, manager of emergency preparedness for Orlando Health, shut down the idea.
“I had to be the bad guy who stepped up and said, ‘No one eat the pizza,’” Alberts (pictured at right) said. “Why? Because this was an attack right down the road from us. We don’t know if it’s been poisoned, contaminated, if we’re the secondary target.”
The episode illustrates the many ways in which hospital and health system leaders have to be quick-thinking when disasters strike their communities. Operating effectively in such situations requires both intricate planning and the ability to improvise.
That was among the lessons imparted during a presentation at HFMA’s 2018 Annual Conference by Alberts; Mason Van Houweling, CEO, University Medical Center of Southern Nevada (UMC); and Brian Dean, CEO, Memorial Hermann Texas Medical Center.
Alberts and Van Houweling lead organizations that received the bulk of the seriously wounded from the two deadliest mass shootings in U.S. history. Dean’s facility was in the middle of Hurricane Harvey, one of the costliest storms on record.
“It was certainly something that we had prepared for,” Dean said, “but at the end of the day, you’re never fully prepared.”
Putting a Structure in Place
The Hospital Incident Command System (HICS) defines roles and responsibilities in the event of disaster, either internal or community-wide. A commonly used version of HICS is sponsored by the California Emergency Medical Services Authority (EMSA).
Hospital leaders should “go back and look at your organizations, and how you are prepared for disaster,” Alberts said. “If you don’t know what HICS is, now is the time to look that up and make sure that you have that system within your organization.”
Orlando Regional Medical Center (ORMC) installed a version with a few differences from the California EMSA’s system. For example, ORMC gives its security officer a place in the HICS command structure instead of having the position report to the operations chief (click on the exhibit below).
Aside from promoting precision during the frenzied immediate aftermath of a disaster, the HICS is a valuable tool in the ensuing days. Dealing with continuing logistical challenges is much easier through a HICS, Van Houweling said.
For example, the clinical situation at UMC was relatively stable on the second day after the Las Vegas shooting, in which 58 people died and 851 were wounded. Of the hospital’s 104 patients, 44 were treated and released within the first 24 hours. Van Houweling thought perhaps the hospital’s Incident Command Center could be shut down the next day.
Instead, it ended up staying open for five more days.
“It was a lesson learned for me because you continue to get the phone calls, and people want to come in and help or visit,” he said.
Echoing Alberts, Van Houweling said hospital administrators should be aware of what goes on in the HICS. Even those who are not actively involved in drills should make a point of observing them.
“Go witness it, go see how decisions are made,” Van Houweling said.
Among other guidelines, the command structure establishes a mass notification system to ensure requisite staff are available after a disaster strikes. Given the instinct of hospital personnel to leap into action, part of the task is to make sure some people stay home initially.
“We did have some whom we didn’t call because we knew that this was going to be a marathon and we needed to have reserves the next morning,” Van Houweling said. “People wanted to come in and help in the moment, but we had to have some crucial conversations about, ‘We you need fresh for tomorrow.’ So that’s something you’ve got to manage.”
With the help of modern weather-forecasting technology, Memorial Hermann and other hospitals in the Houston area had the better part of two weeks to prepare for Harvey. In contrast, neither ORMC nor UMC had advance notice of a mass shooting. But that didn’t mean either was caught off-guard.
ORMC, which has the only Level One Trauma Center in Central Florida, had been holding Mass Casualty Incident drills since 2010. It had conducted such a drill in March 2016, three months before the Pulse Nightclub shooting. (The hospital also performs a trauma-alert simulation at least three times a month.)
Participating in the community-wide drill were ORMC and other area hospitals, the FBI, local police and firefighters, and emergency medical services. The scenario involved an active shooter at a middle school in the county. More than 500 volunteers served as victims who were transported to 15 hospitals.
When the Pulse shooting happened three months later, in the early-morning hours of June 12, 2016, frontline staff drew on the experience they had gained from drilling. ORMC received 38 shooting victims in a span of about 45 minutes, followed about three hours later by a second wave of 10 patients.
“A lot of our staff, from clinicians all the way up through administration, said the exercise helped save lives,” Alberts said. “It helped them get into the battle mode, into the fight mode, and away from the flight mode of wanting to get away from the situation.”
Drilling also is a cornerstone of preparation at UMC—the only Level One Trauma Center in Nevada—which admitted 60 patients after the Oct. 1, 2017, shooting.
UMC trauma surgeon John Fildes, MD, told the Las Vegas Review-Journal that his team drills twice per year on responding to major disasters, and one drill even involved an attack on a concert venue—the very situation that unfolded.
“These county-wide drills are absolutely worth doing with your partners,” Van Houweling said.
Prior to the shooting, UMC had consulted with ORMC to glean lessons from the Pulse shooting that could be applied if a similar situation were to happen in Las Vegas. The medical director of ORMC’s emergency department visited UMC and, among other points, emphasized the need to think about long-term recovery processes for all involved.
Level One Trauma Centers “learn from each other,” Memorial Hermann’s Dean (pictured at right) said. “We actually do some drills together to help prepare for any type of event that we might experience.”
Partnering on Preparations
During a disaster, Alberts said, hospitals will be at a significant disadvantage without the assistance of various agencies. Collaboration with city, county, state, and federal agencies is paramount.
Hospitals should make a point of establishing ties well before disaster strikes, Alberts noted. In the midst of an emergency, agencies such as the FBI may not be inclined to all of a sudden start working together.
“You’ve got to build bridges, you’ve got to build the collaboration now,” he said. “The reason we’re really successful in a lot of this is because of the relationships we built, shaking hands, talking with people … especially the FBI. If they don’t know you, they don’t trust you, they’re not going to talk to you, they’re not going to work with you.”
Cooperation from payers also becomes crucial when hospitals have a sudden surge of patients. Van Houweling commended the assistance of payers in UMC’s efforts to free up space after the Las Vegas shooting. The hospital already was just about full before the shooting.
Because UMC’s payer partners expedited transfer and authorization processes for patients who could safely be moved, Van Houweling said, “We were able to free up 60 beds”—enough to cover the admissions from the shooting.
Expect the Unexpected
No amount of planning can account for every scenario that will unfold during a disaster. During one of the first days after Harvey deluged the Houston metropolitan area, staff at Memorial Hermann TMC received a call from the Coast Guard.
A Coast Guard helicopter was about to land on the hospital’s helipad with a pregnant woman and another woman who had stopped to help. The hospital sent someone out to meet the helicopter and transport the mother-to-be to the labor and delivery unit.
“There’s this poor other soaking-wet woman who says, ‘Can somebody take me home? I have no idea how I got here.’ They’d just told her to get on the helicopter. We ended up giving her a hotel room for three days” since getting home was impossible in the flooded city.
ORMC and UMC dealt with different types of issues in the days after the shootings. In both cases, politicians, celebrities, and dignitaries showed up to offer support to victims, sometimes without notice.
At ORMC, Florida Gov. Rick Scott made appearances on seven consecutive days, sometimes bringing celebrities such as Tim Tebow and Shaquille O’Neal. At UMC, the Nevada governor and lieutenant governor, a senator, and President Donald Trump showed up.
UMC had to accommodate 300 media members from all over the world. Within hours of the shooting, Van Houweling said, “We had reporters from California that were infiltrating the facility. We had to station them within a particular area. That is something you absolutely have to manage.”
What took Van Houweling aback more than anything was the outpouring of community support. While uplifting in terms of intent, such expressions also posed logistical challenges.
Between donations of water, food, and cards and other gifts, Van Houweling estimated that UMC took in four to five tons of stuff.
“That is one thing that I just was not prepared for,” he said. “You’re standing out in front of the property and you’ve got the Coca-Cola trucks and three Walmart semis, and they’re saying, ‘Where do you want it?’ And you’re like, ‘Well, what do you have?’”
Nick Hut is managing editor of Leadership.