EXECUTIVE SUMMARY

Hospitals in the Carolinas faced multiple challenges as Hurricane Florence swept through the region, causing widespread flooding to even inland communities. Facilities in Wilmington and New Bern, NC, report they accommodated many high-needs patients who were inadequately prepared to weather the storm at home or were forced from their homes by floodwaters. Concurrently, hospitals housed and fed staff throughout the storm emergency, which lasted several days.

  • Prior to the storm, New Hanover Regional Medical Center in Wilmington arranged for extra supplies of food, water, fuel, and pharmaceuticals — a step that proved key to helping the community get through the emergency.
  • The hospital went on lockdown a full two days before the storm, giving staff the time and initiative to make arrangements for their families.
  • At CarolinaEast Medical Center in New Bern, patients with high needs began flocking to the ED the day before the storm hit because they were afraid they would be unable to manage at home.
  • While the hospital escaped any major storm damage, administrators note they faced challenges finding the space and resources to house more than 300 staff members adequately while also maintaining a high patient census.

With climate change producing larger and more powerful weather events more often, hospitals and emergency providers have every reason to take their disaster planning and practice drills seriously. It is a lesson medical centers along the East and Gulf Coasts know well. However, this season brought a double dose of reality in the form of Hurricane Florence, which swept through the Carolinas in September, and Hurricane Michael, the most powerful storm to make landfall on Florida’s Gulf Coast, in October.

Some hospitals in the Florida Panhandle sustained so much damage from Hurricane Michael that they had to evacuate most or all their patients even while keeping their EDs open. Weeks after the storm, some facilities still are not admitting patients. It likely will be months before normal operations resume in the coastal communities that were largely flattened by the hurricane-force winds and accompanying storm surge there.

In the Carolinas, the problem had everything to do with water as a slow-moving storm saturated the region with pounding rain for several days, flooding even inland communities like never before. Hospital resources were strained as high-needs patients driven from their homes sought care and assistance in their local EDs.

While emergency providers in the region proved up to the task, some hospitals report that it was fortuitous that forecasters originally anticipated that Hurricane Florence would make landfall with much stronger winds. This caused many to make additional preparations, which paid big dividends.

Stock Up

By Sept. 10, New Hanover Regional Medical Center (NHRMC) in Wilmington, NC, was in full preparation for Hurricane Florence. Hospital administrators anticipated that the city was going to get hit hard. Forecasters expected the eye of Florence to make landfall near the city center. At that point, emergency planners were predicting a Category 4 storm.

“Like all hospitals, we have 96-hour [reserves] of food, water, and fuel, but given the nature of the storm, we decided we needed a little bit more, so we made arrangements to have additional food and water on site,” explains James Bryant, DNP, RN, CEN, CPEN, CCRN, NEA-BC, administrator of emergency services at NHRMC. “We also made arrangements for additional tankers of fuel for our generators just in case we needed them for an extended period.”

Additionally, the hospital worked with its pharmacy and other vendors to ensure extra supplies were on hand. “One of the challenges we had is that the Red Cross made the decision to actually evacuate Wilmington, so agency [administrators] closed their blood center and took their blood products with them,” Bryant says. Concerned that platelets and other blood products could run short during the storm, the hospital imported extra supplies so they would be in place if needed.

NHRMC activated its command center on Sept. 11 and went on lockdown Sept. 12. Consequently, as of 7 p.m. on Sept. 12, staff could not leave the hospital until the lockdown was cleared. Staff members were divided into two 12-hour shifts. One group worked the day shift and the other worked the night shift, Bryant explains. In this case, the in-house staff members were at the hospital for six days before a designated after-storm group provided relief, Bryant notes.

Some of the hospital workers questioned why the hospital went on lockdown a full two days before the brunt of the storm hit. Bryant explains that it was to give families time and initiative to make their own arrangements. For example, some staff members’ families were planning to evacuate the area.

“People could say their goodbyes and hunker down in the hospital, knowing that their families were safely out of the area,” Bryant says.

Prepare to Innovate

The storm made landfall on Wrightsville Beach, just east of Wilmington’s city center, early on Sept. 14. Although the hurricane had been downgraded to a Category 1 storm, the winds still were significant and rain was torrential. The slow-moving storm hovered over the Wilmington area for an extended period, resulting in significant roof damage to NHRMC and leaks throughout the facility. Bryant explains that while the roof remained largely intact, some internal ceilings collapsed. “We closed probably 12 to 15 patient rooms because of significant leaking and we relocated those patients to other areas,” he recalls.

More significant steps were needed to stop water from pouring into NHRMC’s behavioral health hospital where a new building was under construction. First, staff used sandbags, blankets, and dry vacuums to combat the influx, but they then resorted to using a backhoe that was stationed next to the building.

“We were able to take that bulldozer and created a trench around the hospital at about 2 a.m. when the storm was actually hitting,” Bryant says. “This helped to divert water away from the building and to reduce damage.”

When wind velocity exceeds 30 miles per hour, EMS vehicles are pulled off the roads in Wilmington. During the storm’s early hours, volume into the NHRMS ED was very low. “At that point, the only people who were coming in were coming by personal vehicle,” Bryant notes. However, by Sept. 15, the hospital was alerted to an emergency situation nearby where a tree had fallen on a house, killing a mother and her baby and pinning the father down. “The hospital sent over a trauma surgeon, an emergency physician, and one other physician to the scene with EMS,” Bryant says. “We thought the only way to save that patient was to potentially do a field amputation.”

Even though the emergency scene was only a few miles from the hospital, the wind and downed trees slowed the medical team. “Fortunately, by the time the team arrived, crews had already freed the patient, and they were able to transport him to the hospital for care; we did not have to do the procedure,” Bryant says.

Plan for Post-storm Surge

As soon as the winds decreased, ED volume increased, especially patients with significant medical challenges seeking help. These included people on home oxygen who began to run out of oxygen and renal patients who were overdue for dialysis. “Even though they had been given instructions on how to manage for a few days beyond their normal dialysis appointments ... as they started to feel bad, they wanted to come to the ED,” Bryant explains.

To manage these patients, the hospital created what staff affectionately referred to as their oxygen bar. “It was actually just a waiting area that we took over. We placed recliners in there, oxygen concentrators and nursing staff,” Bryant explains. “We cared for these people ... and provided all of their meals until they were able to go back home or to a shelter. We did the same thing with our dialysis patients.”

The dialysis vendor in the area was closed for about two days. When the vendor reopened, it worked with NHRMC to take patients from the ED, staying open almost around the clock to help patients catch up on their dialysis needs, Bryant shares. “Once people were dialyzed, if they had no place to go, they went to shelters,” he adds.

The hospital also ended up caring for several patients who were evacuated from area nursing homes. “Many of these patients were able to stay at other facilities, but some patients had to come to the hospital. We created another area in one of our corridors where we had patients and nursing staff to care for these patients until a special needs shelter could be opened by the county,” Bryant explains. “The hospital’s case management department set up a space in the ED where they worked with nursing homes in the region and the state to relocate patients to other temporary locations.”

On a typical day, the ED at NHRMC sees about 250 people. By Sept. 17, volume had swelled to 360, reaching a peak of 387 patients on Sept. 18. In the aftermath of the storm, patients were streaming into the ED with storm-related illnesses and injuries. “There were significant numbers of people who fell from either trying to cut limbs from trees or from their rooftops while trying to make repairs,” Bryant notes. People whose homes were flooded beyond repair came to the ED looking for answers, too, often with signs of stress or anxiety. “We were dealing with a lot of social issues,” Bryant adds.

Other patients presented with symptoms of possible heart attack or stroke. While most of these cases were ruled out, some patients experienced strokes and heart attacks from all the storm-related exertion that went along with trying to keep their homes safe. “We also saw an uptick in snake bites as snakes and other animals were relocated from their homes due to flooding as well,” Bryant says.

In some areas of the city, raw sewage had seeped into the water, raising the risk of flesh-eating bacteria. Consequently, emergency staff members were alerted to consider this possibility for any patients exposed to floodwaters. “If a patient had a scratch, that was highlighted in our computer system,” Bryant observes. “The physician would get an alert to make sure we informed the patient how to take care of any minor wounds, what signs or symptoms to look for, and to come back if they needed added treatment.”

Staff remained on duty despite the fact many faced storm-related hardships at home. “We had 71 staff members at NHRMC who had significant or total-loss damages to their homes,” Bryant laments.

Recognize Pressure Points

Even though Hurricane Florence weakened significantly before coming ashore, the hospital’s overpreparation proved extremely valuable to the community. “We were able to give fuel to the city of Wilmington to help them keep their fire systems operational during the storm. We were able to take some of the water we did not need and give it to another hospital ... so their chillers and their water would continue running and they would not have to evacuate,” Bryant reports. “Also, our kitchens at NHRMC were so well-supplied with food that they were able to supply food to all of our shelters in the area until the state and other agencies could take over those operations.”

Likewise, the pharmacy at NHRMC filled all prescriptions for all ED patients, dialysis patients, and for all the shelters in the area until relief supplies could arrive, Bryant adds. “I think it was a testament to how well the hospital prepared for this event.”

Nonetheless, there were several pressure points that became apparent during the storm. Hospital staff plan to work with community partners to use what they learned to make improvements going forward. For example, Bryant says it would have been very helpful if the oxygen-dependent and dialysis patients in the region had been better educated on how to optimally prepare for the storm so that they could maintain themselves in their homes for four or five days.

Further, Bryant notes that NHRMC intends to work with county and state authorities on how they can set up special needs shelters sooner next time. “In this case, the special needs shelters weren’t identified [beforehand]. They were set up after the storm. It would really have been nice to have those in place before they were actually needed,” Bryant offers.

While communications channels within the facility performed well, the NHRMC struggled to interact with military assets that were activated during the storm. “The Army and the Coast Guard were using Black Hawk helicopters and other [air transporters] to drop supplies and also to bring patients to our campus, but we weren’t able to always talk to them directly. We were getting messages second- and third-hand,” Bryant recalls. It is an area emergency planners intend to address in the coming months so everyone will be better prepared next time.

Finally, with all the leaks the facility sustained during the storm, administrators had to keep moving the children of staff members who were housed in the hospital during the storm emergency. “We actually cared for 171 children who were sheltered in place with us,” Bryant notes.

The children were housed in conference rooms and other areas that were not used for medical purposes during the storm, but they had to be relocated a couple of times when water began leaking into these areas. Although safety was never an issue, Bryant wants to identify areas that are not so prone to leaking so the children can be housed in a safe, dry area next time, and administrators will not have to deal with the inconvenience of moving such a large group of people during an emergency situation.

Double Down on Preparation

Even several weeks after the hurricane swept through the area, the NHRMC ED continues to see higher-than-average volumes. Many of these patients are reporting with storm-related anxiety or other behavioral health issues. Other patients are presenting with storm repair-related injuries. “We believe this will continue for the next 60 to 90 days at least,” Bryant predicts.

After withstanding the storm’s test, Bryant advises colleagues to consider the benefits of added preparation in their emergency planning.

“We were prepared for a Category 4 storm, but that additional preparation really helped us,” he notes.

For EDs in particular, plan for an onslaught of people with special medical needs, Bryant advises. “Identify nontraditional spaces in your hospital that you can work out of,” he says. “For us, having that vertical intensive care waiting room ... to create space for about 15 patients who were oxygen-dependent, and having a concourse that was kind of isolated but perfect for lining up beds and stretchers to take care of our skilled nursing home patients [were very helpful],” he says. “We were always looking at the next space we were going to go to ... be flexible, because you never know what is going to happen.”

Also, consider how all hospital entrances can be used strategically, Bryant says. For example, he notes that administrators at NHRMC identified specific entrances that could be used for shuttle buses to take patients and families to shelters. Other entrances were designated for ambulances to pick up special needs patients for transport to dialysis centers. “It was almost like an airport, so we could direct people and vehicles to the right space,” he says.

Involving case management at an early stage is a must, as well as leaders rounding with the staff regularly, Bryant advises. “We were all in this together. We were all going to make it through together.”

Anticipate High-needs Patients

Farther up the coast, Hurricane Florence also hit New Bern, NC, hard as constant rain and a fierce storm surge flooded the city to unprecedented levels. Administrators at CarolinaEast Medical Center (CEMC), northwest of the New Bern city center, activated the hospital’s incident command center on Sept. 13, just ahead of the storm’s arrival.

“The day before the storm hit, people were coming in who were afraid they would be left without power and had medical issues at home,” explains Jim Davis, MSN, RN, NEA-BC, assistant vice president of nursing at CEMC. “We got medical necessity types of patients ... bedridden patients and patients who were on oxygen at home.”

The authorities issued mandatory evacuation orders for the area, but people who believed they could not evacuate came to the ED. “Everybody who presented to the ED got a medical screening exam. If they didn’t have a medical issue, and they could go to a shelter, we helped them [find out] where the shelters were and helped them get there, if needed,” Davis recalls. “For those patients who didn’t have another means of receiving their care elsewhere or needed more than a shelter ... we created space to help house them. There were some patients who couldn’t go home because they didn’t have power or couldn’t [access] the medical care that they needed.”

Although downtown New Bern flooded, CEMC managed to escape any serious damage beyond window leaks. However, many staff members were not so fortunate. “One of our nurses was actually rescued from her home and brought into the ED. Of course, she slept for a little while, and then came to work,” Davis shares. “Another nurse I talked to knew her house was flooding. Her significant other was at home and was on the second floor because there was water on the first floor. She was here taking care of her patients with a great attitude.”

The hospital housed more than 300 staff members for the duration of the storm emergency. They slept during the day or at night, depending on when they were designated to work, Davis adds.

Consider Staff Needs

While the storm was bearing down on New Bern, the CEMC only received patients who were brought in by the National Guard or EMS because there was a short period during which people could not get out easily, Davis recalls. “However, during the beginning and ending stages of the storm, there were lots of EMS calls. We saw everything from chest pains and shortness of breath to injuries,” he says. There also were many patients who were rescued from the deluge, some of them with wounds that were infected from floodwater exposure, Davis adds.

Even weeks after the storm, volume into CEMC’s 40-bed ED continues to include storm-related maladies. “We are in the clean-up phase, and we are still seeing lots of injuries,” Davis reports. “If you drive through our town, there are large piles of debris on both sides of the streets from downed trees to peoples’ belongings because so many people were affected here in New Bern ... we will still be experiencing cleanup and rebuilding for six months, if not a year.”

As was the case with the staff at NHRMC, Davis notes that CEMC learned a lot from the Hurricane Florence response. They also intend to use these lessons to make improvements in their emergency response plans. For example, some staff members were holed up in the hospital for four or five days. With sleeping arrangements far from optimal, that is one area administrators intend to address as they prepare for future emergencies. “We learned it is really difficult when you have a large capacity of patients in the hospital to make room for staff to sleep,” Davis offers. “We wanted staff to be able to get rest. However, we had two or three staff members sleeping in one patient room ... all of our staff beds were full of patients.”

Another challenge was finding space and resources to care for people who did not require inpatient care, but could not be discharged. “We had patients who had lost their homes or didn’t have power ... and they had to stay in the hospital for five or six days before we could [find alternative arrangements],” Davis says. “They weren’t really inpatients ... but they were boarding in the hospital.”

Davis notes there also were some high points. “We were very lucky. There were a couple of organizations in the community that really stepped up during the storm and were very helpful to us in helping patients get some of the things they needed so they could go back to their homes ... or to shelters,” he says. “We have learned a lot from storms in the past ... and we will continue to try to get better.”

SOURCES

  • James Bryant, DNP, RN, CEN, CPEN, CCRN, NEA-BC, Administrator, Emergency Services, New Hanover Regional Medical Center, Wilmington, NC. Email: james.bryant@nhrmc.org.
  • Jim Davis, MSN, RN, NEA-BC, Assistant Vice President, Nursing, CarolinaEast Medical Center, New Bern, NC. Email: jdavis@carolinaeasthealth.com.