Field hospital model aids New Orleans ED

Pre-Katrina strategies fall short, only 2 EDs open

You might think that with the population of New Orleans greatly reduced following the devastation of Hurricane Katrina, the city's EDs would find the going a bit easier. However, with only two EDs up and running, the exact opposite is true — and it's taken all the creativity at the disposal of their ED managers to stay on top of things.

At Touro Infirmary, a nonprofit community-based facility, the ED team at first benefited from governmental assistance that included a field hospital model, and once that help departed, the ED manager adopted that model herself to get through a challenging Mardi Gras season.

"We are a 17-bed ED with three overflow beds," relates Helen Ruiz, RN, director of outpatient services, who was the ED director from spring 2004 until June 2006. "Before the storm, Charity Hospital [which has not yet reopened its ED] took all the major trauma cases."

Touro has a fast-track system, created about three years ago, which operates as a separate department. Prior to the storm, annual volume was 25,000 patients for both departments.

DMAT is invaluable

Following Katrina, Touro had to close Aug. 29, 2005, and was evacuated Sept. 1, Ruiz says. "We were on the roof for 48 hours before the choppers came," Ruiz recalls. "We reopened as the first hospital in Orleans Parish on Sept. 28, after a dress rehearsal on the 27th."

This opening was accomplished, she relates, "with the major help of a huge DMAT team [Disaster Medical Assistance Team] and the 82nd Airborne." The 82nd Airborne arrived before the hospital reopened, asked what they needed, and within 24 hours had provided potable water, electricity, hand washing stations, and medical supplies.

The DMAT team stayed until December 2005. "They would see 100 patients a day in their own tent, which included an ICU," Ruiz recalls. "Because of that, all we would get into the ED was about 35 patients a day."

The size of the DMAT team gradually was reduced, and in January 2006, Touro was on its own. "Our volume was almost exactly what it was pre-storm, and we ramped up quickly, but our ancillaries [dietary, housekeeping, maintenance] were still weak," says Ruiz. This weakness was due to the fact there were few places for them to live or eat, so many employees had not returned to the area, she says.

Some the ED team reverted to "the old ways," in Ruiz' words. "We had clinical people doing stuff that was nonclinical." The few ancillaries they did have made the ED a priority, she says, "but we had nurses cleaning beds."

Many people, including patients, ate military Meals Ready to Eat. "We used paper 'everything' so we did not have to have dishwashers," Ruiz adds.

The department was given portable hand washing stations and disposable sheets. "It was almost like field medicine," Ruiz observes. "You just improvised."

Then came Mardi Gras (Feb. 28), when ED volume typically doubles. That's when her experience with DMAT came in handy, says Ruiz. "We set up two huge tents in the streets for triage, with 15 army cots and a draw station," she recalls. "We were able to keep volume inside the hospital normal, since most of what we do during Mardi Gras — intoxication, sprained ankles, lacerations — we did from the tents."

With eight area hospitals closed, Ruiz was able to pull ED nurses from those facilities. "We had applications waiting," she says.

Second ED opens

Meanwhile, on Feb. 14 — just two weeks before Mardi Gras — the ED at Tulane University Hospital and Clinic opened. With such a short lead time, things did not go quite as well.

"We were overwhelmed with patients as opposed to before, with the closing of the other facilities," says Bryan Dean, RN, clinical manager of the ED. "Not only that, we're seeing much more high-acuity patients." One of the problems is that before the storm Tulane had a fast-track area [in the ED] but because the hospital still is under construction, another unit farther away — abdominal transplant — is being used for fast track.

"We've redesigned the ED better to facilitate flow, but we're so inundated we can't handle it all," says Dean. "We've made triage larger. All our equipment is new and approved and easier to use, and has been put in areas that are more user-friendly."

Tulane also has increased security and initiated a medical screening room instead of urgent care. "We've added a clinic-type treatment room to try to facilitate minor care," he says. "We can rotate 10-20 patients a day, but to run that room requires more staffing than we have."

The good news for Dean was that, thanks to outside help, things actually got better during Mardi Gras. "The city's population was lower, even though there was a large influx of visitors," he says. "The federal government sent in two detachments of DMAT units, and the one from North Carolina brought a portable hospital."

The DMAT saw 50-60 patients a day. "Once Mardi Gras ended, however, the DMAT was gone, the portable hospital was gone," Dean laments. "We're just kind of hanging in there, hoping for some state or federal aid."

Sources

For more information on ED surge capacity strategies, contact:

  • Bryan Dean, RN, Clinical Manager, Emergency Department, Tulane University Hospital and Clinic, 1415 Tulane Ave., New Orleans, LA 70112. Phone: (504) 988-1483.
  • Helen Ruiz, RN, Director of Outpatient Services, Touro Infirmary, 1401 Foucher St., New Orleans, LA 70115. Phone: (504) 897-8521.