EXECUTIVE SUMMARY

With several medical facilities in southeast Texas affected by Hurricane Harvey, Franklin, TN-based IASIS Healthcare pooled its resources, shuttled in relief staff from hospitals in other states, and found creative ways to reach hospitals surrounded by flood waters. The massive storm, which swept through the region a week before Labor Day, left the IASIS facility in Beaumont, TX, without water, although physicians and nurses continued to see emergency patients there with liberal use of gel sanitizers. St. Joseph Hospital in downtown Houston created a mass casualty area on a loading dock to manage a surge in patients to the ED in the storm’s aftermath. The Medical Center of Southeast Texas in Port Arthur kept its doors open, taking in patients from Beaumont while also treating patients who presented with storm-related injuries as well as other emergency care needs. However, one hospital employee died tragically in the flood waters. Numerous other staff members experienced flooded homes and/or vehicles.

  • Patients made their way to the hospital in Port Arthur by way of flat-bottomed boats, helicopters, and dump trucks high enough to wade through flooded areas.
  • With a common electronic medical record used at all IASIS healthcare facilities, staff transported from other states to relieve personnel in Texas were able to integrate themselves into the local workflows with relative ease.
  • Emergency staff at St. Joseph Medical Center credit leadership with activating the facility’s disaster protocols early, giving two full shifts of staff time to set up in the hospital before the flood waters hindered access to the facility. The approach enabled the two shifts of personnel to work and sleep in alternating cycles for the duration of the flood emergency.
  • One of the biggest challenges at St. Joseph Medical Center was the surge in patients who required dialysis. With dialysis centers in the region closed, at one point between 30 and 40 patients were awaiting dialysis at the hospital.

The chief clinical officer at Franklin, TN-based IASIS Healthcare, Tedd Adair II, RN, BSN, MA, CEN, CCRN, has been through several hurricanes while working in southeast Texas, so he was perhaps better prepared than most to confront Hurricane Harvey, the juggernaut that swept through the region in late August.

However, the extent of the flooding and devastation left in the storm’s wake placed unprecedented strain on several of the healthcare system’s facilities operating in the affected area.

“We were fine relative to water not coming into our buildings, but we became very isolated on islands, so the typical modality to get a patient or staff member to us was by vehicle until they hit water, and then by flat-bottomed boat, most likely an air boat until they got close to the hospital, and then it was by dump truck ... to bring them up close to the hospital,” Adair explains. “Helicopters were [also] able to get close enough to bring in patients and help us transport patients.”

One of the harder-hit IASIS facilities was its Victory Campus in Beaumont, TX, a satellite of the Medical Center of Southeast Texas in Port Arthur, TX. “The challenge at Victory was ... water overwhelmed the city water pumps and they were flooded, and so they ... quit pumping,” Adair notes. “We moved our patients in-house to our main campus, but we did maintain an emergency presence there. We sanitized as we could with gel sanitizers, but we kept our doors open. There are 150,000 people who live in Beaumont, and we were the only medical facility available to them.”

The other hospitals operating in the Beaumont region closed, so the Victory Campus continued operating with physicians and staff. “We had the ability to get supplies in and out through air transport,” Adair adds.

The main campus in Port Arthur fared better, perhaps thanks to the kind of preparation that evolves from hardened experience. The Medical Center of Southeast Texas had been through four hurricanes before Harvey, Adair notes. “One of those storms was Gustav [in 2008] when we did a full evacuation. It didn’t hit the hospital, but then Ike hit us the next week, so we have punched a hole in the ground and we have our own water supply now,” he says. “We also have our own generation system for power.”

Plan for Staffing Needs

However, with flood waters hindering access to and from the Port Arthur facility, maintaining adequate staffing for an extended period presented multiple challenges. Fortunately, personnel from IASIS facilities in other states volunteered to travel to the region and work shifts in the affected IASIS facilities, helping relieve local staff after long shifts. “Everybody was scheduled with their flight reservations, with the corporation sponsoring and paying for these flights,” Adair explains. “They could not get to Houston because of the flooding, so we brought them into Oxford where we rented buses and vans to bring them in. We set up a basic intake area at St. Joseph Medical Center [in Houston] where every single one of the 75 nurses was processed.”

The volunteering staff members received passwords, a ID badges, cots, and any supplies they needed, Adair says. While some of the volunteers remained at St. Joseph Medical Center to relieve staff there, others required transportation to the hospital in Port Arthur, a route that was 100% impassable by ground, Adair explains. “The Texas Rangers came in with their high-water vehicles and loaded up the nurses,” he recalls. “We moved about 37 nurses over the next 12 hours to Port Arthur with the understanding that they were going to work 12- to 18-hour shifts.”

Integrating the volunteering staff from out of state into the workflows of the affected hospitals was not as difficult as it might have been, given that the corporation has institutionalized many processes and procedures. “We use a common electronic medical record [EMR], and we have a common platform for medication administration, so literally other than having a unique password for the locality and finding out where the break or the supply room is, the volunteering nurses literally went right to work,” Adair observes. “I know some companies have fractured EMRs, and even some hospitals with multiple campuses have different [electronic tools] ... and you lose all the efficiency of being able to pool your resources when you have to.”

Anticipate Post-storm Surges

The influx of fresh staff was invaluable, particularly considering the personal losses that many of the local personnel at Port Arthur suffered from the storm. For example, Adair notes that one employee who reports to him had to chop through his attic to facilitate a roof rescue. “A significant number lost their homes and their vehicles. If the family had a business, it was gone,” he says. “We did have one of our nurses call back when she got home and say that she was done, and was not coming back [to work].”

The toughest loss by far involved an operating room technician who drowned in the flood waters while trying to escape with her infant child. While rescuers were able to save the infant, they could not get to the woman in time, Adair laments. Although the incident was not work-related, it hit the victim’s coworkers hard. “It is really tough. She had worked at the hospital for many years,” Adair says. “[The staff members] are going to have to have assistance and increased counseling support.”

Despite the fact that flood waters hampered access to the Port Arthur hospital, the number of patients arriving to the ED surged from roughly 85 on a typical day to more than 120 in the aftermath of the storm.

“In Port Arthur, we were the only fully operational hospital,” Adair notes. Patients presented with issues ranging from problems associated with exposure to water for a long period and rescue-related lacerations to strokes, heart attacks, and traumas. Adair adds that during the storm period, clinicians performed two emergency coronary artery bypass grafting surgeries, one balloon angioplasty, and they cared for one patient with significant trauma from a motor vehicle accident.

“It was everything we would see on a typical day plus the added complexity of people who were cold, wet, and hungry,” Adair recalls. “We didn’t have any drownings, as those were typically dealt with on the scene by first responders.”

Consider Dialysis Needs

St. Joseph Medical Center in downtown Houston remained relatively unscathed by the storm’s hurricane-force winds, but most of the major roads surrounding the facility were flooded, making it difficult to get in or out of the facility. However, the hospital is just four blocks from the convention center where evacuees were shuttled in by helicopter, creating a gradual surge in volume to the ED once the Houston Fire Department found an access route into the hospital on Aug. 27.

“We saw an increase in volume at that point, but the thing that really increased was the acuity of the patients,” explains Trent Tankersley, BSN, RN, the director of the ED at St. Joseph. Typically, this volume of acute cases would have been dispersed among several medical centers, but St. Joseph was the only hospital downtown that the Houston Fire Department could access at that point, he observes.

“We did see a big increase in patients coming in with flood-related injuries such as broken bones, lacerations, cuts, scrapes, and bruises,” Tankersley notes. “We also saw a lot of injuries related to long-term exposure to water, such as mild hypothermia and some skin breakdown. We actually had one lady who was in labor who showed up in the bed of a dump truck. That was the only way they could get to her through the flood waters.”

Tankersley adds that there was a tremendous problem with patients who needed dialysis. “The dialysis centers were not available and not functioning, so we had one point when 30 or 40 patients were waiting on dialysis,” he says.

The ED at St. Joseph includes 16 acute beds that are monitored and an additional nine fast-track beds, but by Tuesday, Sept. 5, in the aftermath of the weekend storm, administrators needed to create additional capacity. “We developed a plan to actually open up our loading dock as a mass casualty triage and treatment center,” Tankersley explains.

“In that area, patients would actually come in via ambulance or walk in and be seen and treated, unless they needed to come into the main ED.”

The loading dock treatment area supplied an additional eight beds, and it was set up as an extension to the ED, Tankersley relates. “They had diagnostics and IV fluids and medications. We set up a small satellite pharmacy there with a pharmacist,” he says. “We estimate that during the storm period, we saw between 1,000 and 1,100 patients in the ED only.”

Physicians from every department as well as medical students stepped in to help care for patients coming through the ED. “All of that really helped to keep our ED decompressed so that it wasn’t mass chaos,” notes Heidi Wolf, MSNA, BA, RN, the chief nursing officer at St. Joseph. “It was such a phenomenal thing to see everyone come together and work well to take care of that volume.”

Prepare Staff for Challenges

Fortunately, the hospital’s advance emergency planning included enough staffing flexibility to accommodate the increased capacity. “When we called the external disaster [protocols], we requested and were able to achieve a level of staffing where we could staff two shifts,” Wolf explains. “We asked that they remain in the building throughout the storm and during some of the receding waters until we could get relief staff in to work.”

The two shifts of personnel were in place before the storm became severe and access to the facility was hindered. Wolf explains that this arrangement enabled a sufficient number of personnel to sleep and then work in cycles at least until relief personnel arrived.

After working through Hurricanes Ike, Rita, and Katrina, Wolf knows from experience that the biggest surges tend to happen after a storm has moved through. “A lot of it happens with the cleanup, so in order to be prepared you have to start out by preparing your staff to ride through the hurricane or flooding disaster,” she says. “Then, relief personnel need to be prepared to come in, and a lot of times the more extensive piece of the emergency is that recovery phase because it takes so long to get back to normal.”

Wolf adds that it helps if healthcare personnel understand what to expect in a storm as serious and devastating as Hurricane Harvey. “A lot of times the places they have lived in for a long time are so devastated that it is difficult for them emotionally to come back [to work], but if you prepare enough ahead of time, and get everyone in the mindset of what it is going to be like, it seems to make it a little bit easier to handle,” she offers.

The hospital made sure that both shifts of personnel assigned to the hospital during the storm were provided with meals and any resources they needed. For example, if a clinician did not bring a sleeping bag to work, one was provided. In addition, a makeshift canteen was set up in the command center where staff could obtain any personal items they needed.

“People have really stepped up,” Wolf observes. “We have directors here who are doing laundry for their staff. We have just outstanding people who are cooking, bringing in food, and dropping off pallets of water and supplies. There has just been an outpouring from our internal community to ensure that there is quality care for patients in downtown Houston.”

Take Stock of Lessons Learned

In the midst of all the devastation caused by Harvey, there were several instances when staff and patients would cry together, Wolf observes. She also notes that many staff members who experienced severe storm-related losses found coming to work to be therapeutic. “Having a place to come back to some normalcy, like the place of your employment, can help staff get through these events sometimes ... it gives them a routine to look forward to,” she says. “I have found that to be the case at several different facilities.”

With some medical facilities in the region likely to be out of service for months, the hospital is now in the process of planning for extra demand on certain departments for a long period, especially obstetrics, Wolf observes. “We are really concentrating on how we are going to handle the increased volume,” she adds.

Administrators are already examining what steps they might take to improve their planning and preparation for the next natural disaster. High on the list is a better plan for dialysis patients as well as how to handle some of the unique attributes of a long flooding emergency. “Usually these situations last for 24 to 48 hours, but this event lasted so long that we really have to think about having a more detailed plan because there are so many more patients that it affects,” Wolf says. “A lot of people have backup generators ... but with flooding, a backup generator isn’t necessarily going to help you. It is a longer event than any of the hurricanes with wind damage because you just can’t get back to normal.”

There have been many lessons in the response to Harvey, Tankersley observes. “One of the things that myself and some of the other members of the emergency management committee have decided to do is take the experiences that we have had and actually develop a step-by-step plan,” he says. “We learned a lot of things, especially with regard to setting up the mass casualty area [on the hospital’s loading dock].”

Tankersley contends that crafting a carefully developed approach for setting up a mass-casualty site rather than trying to figure it out on the fly will make a difference. “We had a general idea of what needed to be done, but there is only so much a drill can teach you,” he says. “When you actually get into a situation, I think everybody’s combined experience — in the event that there is another situation like this — is going to make it a little bit better.”

Anticipate the Worst

One of the things that the hospital’s executive team got right was calling for implementation of the disaster protocols on the morning of Saturday, Aug. 26, a day earlier than many of the other facilities in the region, Tankersley explains. “There were some moments of hesitation on our part, but it really turned out that they made the right decision at the right time ... and that is one reason why we weathered the storm as well as we did,” he says. “We were prepared in advance.”

Rising flood waters on Saturday evening made it difficult for some hospitals to get extra staff in to work. That meant that existing staff had to work constantly for days. “We called our people in [on Saturday morning] and just tried to stay ahead of the situation,” Tankersley recalls. “We were hoping for the best and planning for the worst.”

Tankersley adds that when a disaster is imminent, it is important not to second guess it. For instance, in the case of Harvey, the storm developed very rapidly. “Within about 24 to 36 hours, it went from a tropical depression to a Category 4 hurricane,” he says. Fortunately, as early as Thursday, the emergency management team was making plans and letting staff know that they might need to come in, and that they would need to be prepared to stay.

With staff working such long hours for an extended period, one would think that tempers might flare and nerves would fray, but it didn’t happen, Tankersley observes. “The staff made it very easy to manage the situation because [clinical and administrative leaders] were able to focus all of their time on managing the crisis, and not on managing difficulties with staff,” he says. “We just didn’t see the difficulties that you would think you would have with 700 people or so living in close quarters for five days in such proximity ... the staff did a tremendous job.”

Look for Talent, Training

While southeast Texas, Florida, Puerto Rico, and the Virgin Islands were all hit hard this year, there will be other natural disasters that affect different regions. Hospitals must be ready. Adair’s advice to colleagues is to look for employees with extra training or military experience that can be helpful in managing disasters. “Not every leader has that experience, and sometimes the calls are tough,” he says.

However, there are many well-trained people in the healthcare delivery system in the United States, some of whom have been deployed in Iraq and Afghanistan, Adair observes. In fact, he notes that such individuals were instrumental in helping set up the mass casualty area on the loading dock at St. Joseph Medical Center during the storm. “Look to the talent you have in your hospital because some of those resources are unbelievably valuable,” he offers. “Make sure to listen to them.”

Further, hospitals that are part of a large network should grease the skids so that they can take advantage of their connections and work cooperatively when a member hospital is under stress and needs help in the midst of a big storm or other disaster. “I enjoy the luxury of being part of a fairly large health system, with 3,500 beds and 15,000 employees in seven states. It is nice to be a part of a family. We are not out here alone,” Adair notes.

“I know some small community hospitals don’t have the ability to pull and push things that I have.”

SOURCES

  • Tedd Adair II, RN, BSN, MA, CEN, CCRN, Chief Clinical Officer, IASIS Healthcare, Franklin, TN. Phone: (615) 844-2747.
  • Trent Tankersley, BSN, RN, ED Director, St. Joseph Medical Center, Houston. Phone: (713) 757-7557.
  • Heidi Wolf, MSNA, BA, RN, Chief Nursing Officer, St. Joseph Medical Center, Houston. Email: HWolf@iasishealthcare.com.