Should hospitals be required to evacuate?

News of 44 bodies found at New Orleans' Memorial Medical Center have raised questions about whether hospitals should be required to evacuate patients in the face of potential disasters such as major hurricanes.

The Tenet Healthcare facility reportedly was dry Aug. 30 when broken levees spilled water onto the streets and quickly submerged the hospital's basement. Efforts to rescue the 256 patients weren't coordinated and suffered from glitches in communication, according to hospital officials.

For three days, the only help that came were two National Guard trucks and four private airboats. The Coast Guard reportedly continued to drop patients at the hospital's helipad even as temperatures rose inside and patients' family members fanned their sick loved ones and helped staff members carry them up dark staircases on stretchers and mattresses.

"They did not die as a lack of care," Memorial Medical Center director of support services David Goodson told the press. "The care of those patients was heroic. These patients were not abandoned."

Some of the bodies were found in the hospital's morgue, apparently people who had died before the storm hit, while others were hospital patients or from a long-term rehabilitation facility operated in the hospital.

"When the storm hit, there was a period when authorities could not help us and people were in there and temperatures were above 100 degrees," said Tenet spokesman Harry Anderson. "Some may have died because of the conditions before the evacuation. No one, no living person, was left in that hospital when we completed the evacuation by Friday [Sept. 2]."

Mr. Anderson said the company continued to check on the dead after the evacuation and pleaded with local coroners to remove the bodies.

"They weren't just left," he said. "We have known about them and have been trying to get them recovered for more than a week."

American Hospital Association spokesman David Allen tells State Health Watch that there are no mandatory evacuation requirements and that facilities must individually make decisions based on their own circumstances, both where they are located in relation to a storm or other disaster and how easy it is to move their patients.

"There are difficulties involved in evacuating hospitals," Mr. Allen says. "Hospitals have to look at where they are in the flood plain and whether there is a helipad available. They have to determine if it is possible to bring patients down by hand from upper floors and take them out by boat."

Evacuation is a local decision

According to Florida Hospital Association spokesman Rich Rasmussen evacuation decisions are made by local government officials and the management of hospitals. Hospitals can request evacuation, he said, but resources may be stretched thin as many other people try to evacuate at the same time. Also, he said, hospitals need to evaluate their patients' conditions and determine if trying to transfer them actually could be more dangerous than staying in place.

Mr. Rasmussen noted that Florida hospitals have been built to very stringent codes that generally make them better able than most commercial buildings to withstand a hurricane's fury.

"Even in the worse hurricanes that have hit Florida," Mr. Rasmussen tells State Health Watch, "our hospitals have primarily suffered roof damage and not major structural damage. Also, hospital generators are usually above ground level and able to continue providing power."

Getting ready

Three weeks after the hurricane hit, East Jefferson General Hospital CEO Mark Peters testified on behalf of the American Hospital Association before the House of Representatives Energy and Commerce Health Subcommittee and Energy and Commerce Oversight and Investigation Subcommittee on the status of his Metairie, LA, hospital and the general situation with hospitals. Mr. Peters noted that his 450-bed tertiary care facility has been able to remain open and care for patients, one of four hospitals still open in the New Orleans area.

"Knowing that the huge storm was heading their way," Mr. Peters said, "hospitals began sending home ambulatory patients. Those in critical condition or requiring special assistance, such as ventilator-assisted breathing, remained in the hospital. When hospital staff reported to work on Monday, they knew it might be a few days before they were able to return home. When the levees in New Orleans broke, however, the situation changed dramatically."

Before the storm hit and roads were closed, East Jefferson moved its neonatal unit to Women's Hospital in Baton Rouge and many other patients were transferred to facilities both in and out of state. Mr. Peters said they did not transfer ventilator-assisted patients, fearing the risk to their health during a transfer would be too great.

He discussed the difficulties in obtaining food and in restaffing, as well as problems with communication and security. Throughout the storm, he said, the first priority always was patient safety, with staff safety second, although only by a hair.

"Obviously, other hospitals in the Gulf Coast region went much longer before relief arrived," Mr. Peters reported. "They relied on generators until fuel ran out, all the while trying to arrange the means to evacuate patients and hospital staff. In New Orleans, of course, the situation was exacerbated by the rising flood waters, as patients were carried up flights of stairs to drier floors, and authorities tried to arrange air and water evacuations."

Setting priorities

Current needs in the area at the center of the disaster, he said, include restarting cash flow to affected health care facilities, relieving staff, obtaining temporary housing, and accessing fuel.

"As we assess the damage and attempt to rebuild our facilities, it is critical that we find a way to improve our cash flow. If we have no patients, we have no income. If we have no income, we have no way to pay our workers, to obtain services such as food and water, and to continue providing health care services to areas that have already lost so much of their infrastructure.

"Every tragedy and disaster provides lessons to either avert the next one or, if that is not possible, mitigate the consequences," Mr. Peters added. "This disaster is no exception. During the last few weeks, we've learned a number of valuable lessons and gained some insights on how best to work together. We realize that response to disasters is always ad hoc at the start, when it is best to rely on good judgment rather than policies and procedures.

"We learned this time, as we did with the events of Sept. 11, 2001, that communication systems are the first thing to go. From our experience at East Jefferson, it is obvious that an alternative reliable communications service must be in place, so that public officials, first responders, and the health care community can efficiently communicate their needs, situations, and availability to assist," he concluded.

[American Hospital Association information on hospital emergency plans is available on-line at www.aha.org. Contact Mr. Rasmussen at (850) 222-9800.]