Be Prepared
Unpredictability of Mother Nature - and human nature - prompts more hospitals to examine and upgrade their emergency response systems

By Scott Williams
January 30, 2003

The Methodist Hospital in Houston was among several to declare internal disasters in June 2001 when Tropical Storm Allison dumped as much as 20 inches of rain on the city in a 24-hour period.

Methodist, like other hospitals that have either been through disasters or drilled for them, has learned from its experience and taken measures to better handle the next disaster.

Basement flooding destroyed the hospital's pharmacy, three MRIs, nuclear cameras, food preparation areas and millions of dollars worth of supplies. The hospital lost its air conditioning, water and elevators, and had to evacuate critically ill patients to a nearby hospital via a sky bridge.

The amount of rain that fell on the city that day occurs on average once every 100 years. But Methodist, like others in the renowned Texas Medical Center, home to more than 40 health care facilities, isn't taking any chances. It's prepared in case Mother Nature ignores statistics and delivers the next 100-year rainfall ahead of schedule.

Doug Rand, who became director of facilities at the hospital two days after Allison hit, said one of the most important lessons learned was how vital it is for hospitals in the Texas Medical Center to communicate.

Open channels

"The first thing that was learned was that the ability to communicate was compromised and since we are adjacent to other entities and their facilities, it was important that we get together as a group of hospitals," he said.

Some hospitals, including Methodist, had perimeter flood protection systems in place, but it was quickly learned that hospitals that activated their systems first jeopardized their neighbors by forcing water their way. So, after the floods, representatives from each hospital came up with a procedure that calls for them to activate their flood protection systems at the same time.

The systems will be activated when the water in a nearby culvert reaches a specific level. The culvert is monitored 24 hours a day via a camera that broadcasts the water reading over the Internet. Furthermore, personnel at each hospital have been trained to activate all the flood protection systems in case one or more hospitals needs help.

That shouldn't happen at Methodist. Enough facilities people are on hand at all times to implement the new flood prevention measures. Those measures include submarine doors in the basement levels that can be closed and sealed with inflatable rubber bladders to prevent water from adjacent hospitals, which are connected by underground corridors, from flooding their neighbors. Methodist is connected to two hospitals and three other health care facilities by 9-foot-wide, 10-foot-high corridors.

On call

Other measures include a 24-hour wireless radio dedicated communication system to allow staffers to communicate with one another in case the hospital's telephone lines and Internet connection go out.

Memorial Hermann Hospital was hardest hit by the flood. The hospital evacuated patients by air and ground ambulance when flood damage forced it to close.

Tom Flanagan, administrative director of emergency services, said hospital directors quickly learned that it's a good idea to have call lists with them at all times. Most kept their list of people to call in the event of a disaster in their offices because they expected to be able to get to work when a disaster struck.

But the flooding prevented that in many cases and the carefully compiled call lists were rendered useless. Now, most hospital directors have their call lists on their Palm Pilots, he said, which they carry with them at all times.

Flanagan said the hospital also is in the process of developing an evacuation plan, something it didn't have when it was forced to shut down. "Our safety committee for the hospital is looking at developing a mock disaster drill, where you would have to evacuate the hospital and how would we go about doing that."

Many hospitals in the Texas Medical Center, which sits at the lowest elevation in Houston, quickly learned that placing emergency generators in the basement was a bad idea. The basements flooded immediately and the water shut down the generators. Methodist was one of the few that had emergency generators on risers outside the hospital, Rand said.

Unfortunately, the distribution equipment used to deliver power to the hospital was below the floodplain, making it useless once the water reached it. "That equipment was in the basement, so once that got wet, we were now losing even emergency power even though the generators were running away," Rand said. That equipment has been moved to a level 1 foot above the 500-year floodplain.

Plan of attack

Methodist has always been prepared to handle an external disaster involving a large number of patients, Rand said, but since Sept. 11, it has taken measures to protect against assaults on the hospital itself. Recent measures include fencing to keep people away from loading docks and other areas where they might enter the building, and disguising intakes that provide fresh air to its heating and air conditioning system.

The hospital also has fenced off access in ways that don't attract attention and, twice a day, facilities personnel check the utility systems where they come into the building to make sure they haven't been tampered with.

The events of Sept. 11 have forced hospitals throughout the country to examine their disaster response/emergency preparedness plans. Hospitals that traditionally have focused their response on natural disasters and accidents have been forced to examine more earnestly how they would respond to mass casualties, as well as victims of chemical, radiological and biological attacks.

Marianne Klaas, MN, RN, director of accreditation and safety at Swedish Medical Center in Seattle, said her hospital began gearing up for such eventualities long before Sept. 11. That's because Seattle, which would later be the target of a plot to bomb the Space Needle, hosted the World Trade Summit in 1999 and was warned to be ready to deal with victims of chemical attacks. As it turned out, the protests, although violent, did not involve the use of chemical agents.

Seattle, like cities around the world, also geared up for potential disaster (Y2K) as the year 2000 approached and Feb. 28, 2001, experienced a magnitude-6.8 earthquake.

Emergency gear

Swedish Medical Center has spent tens if not hundreds of thousands of dollars on equipment to protect employees and decontaminate victims of a chemical attack, Klaas said. Although the hospital has never experienced such a disaster, it has conducted simulation drills using a busload of Army soldiers playing victims.

"You have to make sure you have the proper surveillance and triage of victims when they go through your doors to make sure they don't contaminate your staff and the building," Klaas said. "[You also have to make sure you] have the proper ability to diagnose and treat victims once they come into your building."

Among the lessons learned through the drills, Klaas said, is the importance of having clear lines delineating the various "hot zones" where highly contaminated, mildly contaminated and clean victims are kept. Victims who are clean, for instance, need to be kept separate from other victims to prevent them from being recontaminated.

Another lesson learned was how difficult it is to communicate while wearing protective gear, in large part because the respirators medical personnel have to wear make noise.

"We had to go back to the drawing board to figure out a hands-free means of communicating, so we didn't have to walk over and yell at the next person or write something down," Klaas said.

Protective gear now includes hands-free radios. The hospital also discovered that people using the protective gear need to be spelled after an hour or two, meaning it's important to make sure the hospital has enough people on hand to take over when they need to rest.

Health care professionals also learned that it's important to decontaminate victims using tepid water, Klaas said, because cold water can cause hypothermia or lead some victims to cut short their shower before they're completely decontaminated. Water that is too warm can dilate blood vessels and speed the flow of contagia through the body.

Klaas said the drill forced them to look at the logistics of the showering process, patient identification, marking of valuables and the flow of patients. They also had to consider how willing victims would be to shower naked as compared to the soldiers, who showered in shorts and T-shirts.

Like other hospitals, Swedish Medical Center has received funds from the federal government to help it pay for special equipment needed to decontaminate victims and protect health care workers. Its decontamination tent cost $15,000 and respirators, 15 of which had to be purchased at each of its three campuses, cost $1,000 each.

Washington state is working to make sure the equipment used statewide is the same, Klaas said, so that workers from other parts of the state brought in during a disaster will know how to use the equipment. She said once the immediate problems subside, hospitals must go through substantial financial recovery and reimbursement, as well as a debriefing and an emotional recovery process.

"It would be horrible to lose a good worker because they're so shaken they won't be able to help you in the future," she said.

All systems go

Swedish Medical Center uses the Hospital Emergency Incident Command System (HEICS), which originated in California, to guide its actions during an emergency, Klass said. The system and the drills that are mandated either by state law or the Joint Commission on Accreditation of Healthcare Organizations has made its response to disasters much more effective, she said.

"We haven't had the horrendous chaos we would have experienced five to 10 years ago," Klaas said. "We have the structure and support in place to get us through it."

Maribeth Woitas, RN, director of emergency services at North Memorial Medical Center in Robbinsdale, Minn., said her suburban Minneapolis hospital also employs the HEICS program.

The system has been used in California for at least 10 years and is modeled after the Incident Command System used by public emergency services agencies. HEICS uses a logical management structure, defines responsibilities, and uses clear reporting channels and a common language to help hospitals coordinate their response with other emergency responders.

Woitas said in an emergency, people are assigned to positions on an organizational chart and given a job action sheet with prioritized tasks that are checked off as they're completed. She said the system allows hospitals to assign people to essential positions even when they're not familiar with the plan. She said HEICS is a flexible system that also tells people how and with whom to communicate, and spreads responsibility among many people.

"You're able to respond to a much larger situation than if we have just a few departments trying to respond to whatever the disaster scenario is," she said. "We have always had [emergency] plans, but we have made them more detailed and we have created a plan that enables us to deal with much larger numbers of casualties."

Woitas said disaster drills have exposed communications problems that led North Memorial to devise a manual communication system using runners, message forms and a communications officer logging all messages. She said the hospital, which sometimes has to call "snow emergencies," has a callback system used to summon workers back to the hospital.

The Twin Cities area is in the process of implementing an 800-megahertz radio system that emergency personnel can use to communicate when telephones aren't working, she said, and could be used to allow hospitals to communicate with one another.

Maggie Duplantis, RN, nursing director at The Methodist Hospital in Houston, said the hospital devised a management alert system that can send a text message by pager to hundreds of hospital personnel at the same time. The message, for instance, could alert personnel about an emergency situation and tell them to stand by for further information.

"Then if you do need certain people to initiate their unit disaster plans, that information can be distributed," she said.

Duplantis said her hospital also has taken employee needs into account in its emergency plan. The hospital has an area that can be designed as a day care center for employees with children who may need help in emergencies. They also have a policy that allows employees to leave to care for family and said the hospital would find a place for other family members should its employees need help.

Duplantis said she hopes never to experience another disaster like the one that struck Houston in June 2001. But, having gone through the unthinkable, she knows not to assume that something like that will never happen again.

"Never say it won't happen to you, it won't happen to your hospital," she said. "Always be prepared."

Contact Scott Williams at scottwilliams21@msn.com