Hospital case managers respond to World Trade Center attack

Saint Vincents’ CMs cope with unique challenges in wake of tragedy

On the morning of Sept. 11, Toni Cesta, PhD, RN, FAAN, director of case management at Saint Vincents Hospital in Manhattan was at her desk when her secretary informed her that a Code Three had been called. Assuming the announcement was part of a routine disaster drill, Cesta asked what scenario had been given and was told an airliner had crashed into one of the twin towers of the World Trade Center. "I said, Oh, how silly. Couldn’t they come up with something better than that?’" Cesta recalls.

But the scenario wasn’t fictional, and this time, the disaster wasn’t a drill. Within minutes, a second jet slammed into the other World Trade Center tower, and soon both buildings collapsed. In the confusing hours that followed, the number of dead and injured was unknown, and area hosp-itals braced for the worst.

At Saint Vincents, a Level 1 trauma center two miles from the World Trade Center Complex, dedicated professionals rose to the unique challenge of responding to the attack, treating survivors and rescue workers; offering comfort, counsel, and vital information to family members of the victims; and supporting each other at a time of crisis in their own community.

For Cesta and her case managers, there was no time for shock or disbelief. The most important and immediate consideration was to free up as many beds as possible as quickly as possible, in case of mass casualties. "We all have a place where we’re expected to report, as per the disaster plan," Cesta says. "When my case managers reported to that location, we just sent them right back to the units. I said, Just start discharging everybody.’"

The process of rapidly discharging current patients was complicated, however, by local rescue efforts and by safety precautions being enacted beyond the hospital walls. The hospital was cordoned off, and no traffic was allowed to move in that part of the city. "We really had to work with the police department very closely and with various transportation companies" both to facilitate discharge and to get staff to the hospital for work, Cesta says.

"If we took three patients out to Staten Island, we would bring back three nurses who needed to get to work," she says. "There was a lot of coordination of transportation. That was really what I was doing for about two days."

By the second day, more transportation help was available. "But that first day was very difficult, simply because we were in a nonaccessible area, and any ambulances that were around were being used at the disaster site, which was appropriate," Cesta says. "We got into this situation where we needed to get patients out of the hospital, but we had limited resources to allow us to do that." Two babies born during that time were taken home in police cruisers.

Meanwhile, case managers were still fielding health plan calls for insurance reviews. "I told my staff, Don’t even respond. That is not where our focus is. If we don’t get paid, we don’t get paid,’" she says.

Fortunately, it didn’t come to that, thanks in large part to the efforts of the New York City-based Greater New York Hospital Association (GNYHA), which stepped in quickly to encourage insurers to waive precertification notifications and some medical management requirements for a period of time. "Our president sent a letter to about 24 different plans that operate in the metropolitan area, asking for their continued flexibility and support," says Lillian Forgacs, associate vice president for utilization management and managed care at GNYHA. "It explained to them what the exact challenges were to the hospitals, and some of those challenges actually were shared by the payers, too."

Indeed, one plan’s information system was housed in the World Trade Center, "so they were totally crippled," Forgacs says. "We said to them, Do you want to fax us something that we get out to the membership to let them know?’ and they were incredibly appreciative of that."

Cesta also was appreciative of GNYHA’s efforts, which led plans to establish grace periods that ran from a few days to a few weeks in length. "They stepped in and said, We can’t continue to conduct business as usual here. You’re just going to have to certify everything, because the hospitals are not going to be able to respond in a normal fashion to the utilization requirements,’" Cesta says. "And [the plans] quickly did respond, and so we were able to know that we would not have to deal with precert issues or continued stay issues, that things would be paid for and we could keep our attention on pushing the patients through the system and deploying the staff and really do discharge planning."

Despite the distractions and difficulties they faced, Cesta and her staff were successful in clearing bed space. "Of course, the disappointment in all of it was that we didn’t get as many patients and as many survivors as we would have liked to have gotten," Cesta notes. "That was the tragedy in this."

Many of the patients who did come in were injured rescue workers, many of them covered in the gray powder that billowed around the attack site, their throats raw and their eyes blood-red with irritation. Common problems included smoke and particle inhalation and minor injuries caused by moving among the debris.

After the first few days, however, the type of patients presenting to the hospital shifted, as local residents in various stages of coping with the disaster sought emotional support and counseling. The social workers in Cesta’s department assisted in the effort to help these patients, as did Saint Vincents’ supportive care program.

Like case management, supportive care had had its hands full since the attacks occurred. "We started to see in the hospital an almost immediate arrival of concerned family members," says Eileen Hanley, RN, MBA, manager of the program. "As soon as word got out that people were coming to Saint Vincents, we began to get calls, then people arriving here at the hospital. So our program staff did a lot of manning the phones in the phone bank." By midafternoon of the 11th, staff realized they needed to set up a separate center outside the hospital to deal with the needs and concerns of family members.

The family crisis center was established a couple of blocks away with the help of case managers, social workers, and supportive care staff, and during the few days of its existence, it received an estimated 6,000 people. "What happened was that for a couple of days, Saint Vincents was the only place family members could come to get information, because the city’s office of emergency management was damaged in the trade center collapse," Hanley says. "It took them a couple of days to set up their city center, which ultimately took over the centralized function. But for about two or three days, Saint Vincents was the hub of information for people."

At the center, hospital workers from various departments staffed tables at which family members could inquire whether their loved ones had been treated at a local hospital. "At that point, very soon after the disaster, people were looking for concrete information," Hanley says. "They weren’t coming in requesting counseling. What was valuable about our staff being there was that, in the process of helping to look for a name on a list, they could do a very quick assessment of how this person was managing."

Once the city’s official center was up and running, the work of the family crisis center was moved back to the hospital. By then, its function had become less to disseminate information than to provide counseling. "People were going to the city center to file missing persons reports, to bring in DNA samples, and things like that," Hanley says. "But what we were seeing were people either directly affected by the trade center disaster or people who were really anxious or scared or sad and wanting to talk to someone. So our staff, together with our spiritual care department and psychiatry department, helped to staff that center for about a week and half, around the clock."

Case management and supportive care staff helped out in the emergency department, where bereavement and grief counselors also were on hand to assist incoming patients. "One of the things that we found very helpful was that the case managers who were in the emergency department often were able to identify people they thought were appropriate for the counselors to reach out to," Hanley says.

In some cases, those considered appropriate for counseling weren’t patients but staff members, all of whom had worked long hours under incredibly stressful conditions in the aftermath of a disaster in their own community. Twenty-eight Saint Vincents employees lost family members in the attack.

By the middle of the second week, when the volume of family members seeking information and counseling began to dwindle, the supportive care staff began focusing their efforts on employee support. They developed materials to help employees cope with what had happened, and at press time, they continued to circulate throughout the hospital, speaking informally to staff about how they’re coping.

Cesta also turned her department’s attention to staff support, because, as she says, "many of the staff had been unable to go through their own [coping] processes because they were so busy. They really put their own feelings aside, and then those issues started to have to be dealt with. So the hospital has set up workshops for staff to go to, to talk through their feelings about what happened."

A remarkable response

But as difficult as the situation was, Cesta is proud of how her hospital and her community responded in the wake of the tragedy. "People were tired. Emotions were high. But everybody stayed very calm," she says. "They really did a great job — everybody. The front end, the back end, and everything in between. People were here to do whatever had to be done and step up to the plate."

That willingness to help spilled over into the community at large as well. At one point, about 1,000 people were lined up literally around the block waiting to give blood. "Eventually, we couldn’t take any more blood, and we referred people to other hospitals to give blood there," Cesta says. "Giving blood was a concrete thing that people could easily do, and so we had more blood than we needed. I wish we could have used it."

For days after the attack, Saint Vincents’ hallways were plastered with photocopied pages bearing pictures and descriptions of missing loved ones. As time passed and hope for finding more survivors dwindled, the pages were taken down and moved to a single location. In time, they will be bound together in a book, and the book placed permanently in the chapel as a reminder of all those Saint Vincents never got the chance to treat.