EXECUTIVE SUMMARY

It was a different kind of emergency in the Midwest as temperatures well below 0 degrees Fahrenheit began to hover over the region in the waning days of January and early February. Hospitals and EDs responded by serving as warming centers for people seeking shelter while also gearing up for frostbite, hypothermia, and other cold-related maladies. Some hospitals activated their incident command procedures while others leveraged their daily huddles to make sure both staff and patient needs were addressed.

  • The ED at Regions Hospital in St. Paul, MN, saw 34 patients arrive with frostbite between Jan. 28 and Feb. 1, and made space for homeless individuals until law enforcement could transport them to local shelters. When temperatures began to ease, the ED saw record volume due to injuries from slick and icy conditions. Most of these cases involved head injuries from falls.
  • In Chicago, Mount Sinai Hospital and Holy Cross Hospital served as warming centers for homeless individuals. The Sinai Health System, which operates both hospitals, activated its incident command to address staffing and other cold-related issues.
  • Just west of Chicago, Loyola University Medical Center began its preparations for the polar vortex by making sure that all patients who could be discharged safely were released before temperatures plunged. While patient volume was not a problem during the cold emergency, the number of patients directed to the hospital’s burn unit doubled, including frostbite cases as well as patients injured during house fires that resulted from space heater use.

While the Midwest is accustomed to cold weather, the bone-chilling blast of freezing temperatures that swept through the heartland at the end of January provided added challenges to hospitals and EDs in the region.

The so-called polar vortex ushered in ultralow temperatures in several states. The coldest temperature (minus 56 degrees Fahrenheit) was recorded early on Jan. 31 in Cotton, MN, with other communities in Wisconsin, Illinois, and Iowa charting record or near-record lows. The harsh environmental conditions forced schools and businesses to close and created heightened risks for people who needed to venture outside their homes.

Meanwhile, hospitals in the region not only had to prepare for frostbite, hypothermia, and other cold-related issues, but also an influx of people seeking shelter.

Further, facilities needed to make provisions for staff members, many of whom found it safer to bunk at work than to face the risks posed by the plunging temperatures. Hospitals in St. Paul, MN, engaged in community-wide planning for the deep freeze that hovered over the region during the last days of January and early February.

Of particular concern was the plight of the city’s homeless population, which is generally the group most at risk for developing cold-related injuries and conditions, explains Kurt Isenberger, MD, chair of the ED at Regions Hospital, a Level I trauma facility in St. Paul, and an assistant professor of emergency medicine at the University of Minnesota Medical School.

“With this in mind, we partnered closely with our county’s undersheriff to coordinate our plans for addressing the cold and keeping people safe,” Isenberger says. “In our community, shelters extended their hours and expanded their capacity. Law enforcement picked up those without shelter and transported them to warming spaces. Here at Regions, we arranged to keep homeless people in the hospital until law enforcement could come and transport them to local shelters.”

The ED at Regions generally sees about 240 patients per day. This trend did not change when the polar vortex hit the area, but the effect of the plunging temperatures was evident in a handful of hypothermia patients who arrived and a sharp increase in patients presenting with frostbite.

“From Jan. 28 through Feb. 1, we saw 34 patients with frostbite. During an average winter week, we usually see five to six frostbite cases overall,” Isenberger notes.

Typically, the treatment for patients with frostbite involves rewarming the skin with warm water, measuring between 98 degrees and 108 degrees Fahrenheit, for 15-30 minutes.

“Frostbite and the rewarming process can be painful, so we also treat [patients] with oral pain medication as needed,” Isenberger says. “Then, we apply sterile dressing to protect the skin, separating fingers and toes. If blood flow is not restored with this method, we then admit patients to our burn center, which can provide specialized treatment for this injury.”

While volume into the ED remained in check during the deep freeze, patients presented in force when the cold began to ease.

“On Feb. 4, we saw a record number of patients in the ED [335] due to very slick and icy conditions. The majority of these were head injuries from falls,” Isenberger recalls.

This is when all the hospital’s regular simulations of patient surges during mass-casualty events came into play. “We’re ready for these instances,” Isenberger notes. “We were able to call in extra staff members, open up additional beds in the ED, and convert spaces like surgical recovery and waiting areas into patient care spaces.” Ultimately, on Feb. 4, the ED treated 93 patients with injuries related to the icy conditions, Isenberger adds.

Address Staffing Concerns

In Chicago, the Sinai Health System, which operates Mount Sinai Hospital and Holy Cross Hospital, worked with the city to prepare for the plunging temperatures.

“We participated in citywide calls so that all the hospitals [in the region] would be prepared and have a plan for those who were displaced and/or needed a warming shelter temporarily,” explains Michele Mazurek, RN, MSN, MBA, CCRN, chief nursing officer and vice president of patient care services at Sinai Health System.

Both Mount Sinai and Holy Cross were used as designated warming centers, Mazurek notes.

“Folks were welcomed in, given shelter with warm blankets and winter accessories (if needed), and hot drinks and food were also provided,” she says. “If people needed a longer stay, the city provided warming buses to the hospitals to give those in need a ride to area shelters. Sinai saw about 30 people and a few families between the two hospitals.”

Provisions also were made to ensure that hospital staff could make it to work throughout the deep freeze.

“Sinai transportation was available to provide rides to those whose cars did not start or who took public transportation. Some of the public transportation systems were not running at full schedules or capacity,” Mazurek relates. “Sinai operations opened a command center so that calls could be funneled and answered immediately through the system.”

The command center fielded calls pertaining to staffing or any other cold-related issues, Mazurek says.

“This provided the hospitals with a centralized center to take care of all needs so that units could focus on providing care to our patients and visitors,” she explains, noting that both hospitals remained fully staffed throughout the period of record cold.

Mazurek adds that cold snaps and emergencies are not uncommon for Sinai’s EDs, considering the large number of trauma cases that move through the health system. While staff at Mount Sinai and Holy Cross treated a few cold exposure-related injuries, including one that was severe, they did not see a big increase in these types of injuries.

“I believe this was due to the early warning systems that the city and media put in place to alert residents to the dangers of the upcoming weather,” Mazurek offers. “There were also many public announcements about warming shelters and hospitals being used for refuge from the cold. The Chicago Fire Department and Chicago Police Department were very active in making sure the homeless population was evaluated.”

Mazurek stresses that preparation and strong leadership oversight at the executive level are keys to managing these types of emergencies and ensuring staff members have the resources they need.

“Round on your caregivers,” she advises colleagues. “With extreme weather and school closings, many staff had to find child care, dig their vehicles out of street parking, and deal with the cold themselves. We provided hot beverages to all our caregivers to warm them up and thank them for coming in to work on days when many other professionals got to stay home.”

Leverage the Huddle Process

Just west of Chicago, Loyola University Medical Center began its preparations for the polar vortex by making sure that all patients who could be discharged safely were released before the plunging temperatures arrived. This involved making sure that family members were coming in as scheduled and, in some cases, arranging for transportation home.

“Simultaneously, we were ensuring that beds were open and available in the burn unit for potential frostbite cases, hypothermia, and anything involving the hands or feet,” explains Mark Cichon, DO, FACEP, FACOEP, chair of Loyola University Medical Center’s department of emergency medicine. “The focus institutionally was to ensure there was sufficient staffing, services, and appropriate transfer of patients coming into the institution and through the ED.”

Cichon adds that ensuring unimpeded care throughout the Level I trauma center’s multiple units (including the neonatal ICU, pediatric ICU, burn ICU, transplant program, and cancer service) was prioritized.

Much of the operational decision-making throughout this period was conducted through the morning huddle, which is designed to anticipate all the challenges or limitations that the hospital may encounter on any particular day, Cichon notes. For instance, providing food for staff was part of this discussion.

“A few of the coffee shops on campus were consolidated into the main cafeteria to ensure [adequate] staffing,” he says. “Also, there were cots set up and available for any staff members who couldn’t get home or didn’t want to attempt to get home.”

Loyola’s medical school closed during the deep freeze, creating some housing resources such as shower availability for any staff members who stayed on campus throughout the emergency.

Considering the polar vortex affected the entire state of Illinois, the governor authorized a state of emergency, making extra resources available in the prehospital environment, including additional vehicles to transport affected individuals.

“The state, through the department of public health, tracked cold-related injuries on a daily basis. That data had to be put into the state computer because [while the state was] tracking it on a global basis, we were tracking it on a regional basis,” Cichon says.

While patient volume was not a problem during the cold emergency, the number of patients directed to the burn unit doubled. This included frostbite cases as well as patients injured during house fires that resulted from space heater use, Cichon explains. Further, the acuity of patients presenting to the ED was higher than normal. The department also faced an influx of people simply seeking shelter from the cold.

“We are fortunate in that we have social workers in the ED as well as nursing case managers who helped set up transportation to homeless shelters that were available. They had been proactive in getting the [appropriate] names, numbers, and all of those things in anticipation,” Cichon notes. “Also, people in the institution and members of the ED took the initiative and brought in extra clothes and jackets, knowing that we would probably encounter some homeless people.”

Once temperatures returned to what is normal for the region, volume picked up in the ED, perhaps from lower-acuity patients who resisted leaving their homes while environmental conditions were so harsh.

For instance, on Feb. 4 (which fell on a Monday), the ED saw close to 160 patients, up from the average per-day volume of 135. However, Monday typically is the busiest day of the week, Cichon observes. Cichon’s advice to colleagues faced with a similar weather emergency is to leverage their morning meetings fully to address anticipated challenges quickly.

“That is the beauty of having that morning huddle,” he says. “It allows the opportunity to discuss lessons learned immediately — not the next day — and to be proactive.”

However, ample, long-range preparation also is important. “Know the infrastructure needs of the institution,” Cichon advises. “We had teams available at all levels — medical, electrical, pipefitters, physical plant, and grounds people — to ensure that the ship was staying afloat.” Quickly adjusting to new challenges takes practice, but is important when you are in uncharted territory. For instance, Cichon, who has spent his whole life in the Chicago region, has experienced plenty of cold temperatures. Still, the polar vortex of 2019 was different.

“It was much more pronounced, it occurred quicker, and it lasted for about 40 to 60 hours,” he says. “It was another character-building day in Chicago. My hope for the next one is to get that character-building day in a warmer environment.”