Hurricane Sandy puts NJ hospital under extreme stress, highlighting vulnerabilities, areas requiring improvement

Advice from hospital administrators: Regularly test for multisystem failures

When Hurricane Sandy was taking aim at states along the northeastern coastline in late October, hospitals and emergency management officials in the region had several days to prepare. But the storm proved once again how difficult it can be to respond to a national disaster of this magnitude, and how important it is to have multiple layers of contingency plans in place in case crucial systems go down.

While the storm caused dozens of fatalities, perhaps miraculously, there were no reports of lives being lost as a result of hospital systems going down. However, at least four hospitals in New York and New Jersey had to be evacuated when their back-up generators failed. This put added stress on other hospitals in the region that were already dealing with surges in demand from patients who could not get in to see their own physicians or even fill needed prescriptions during the height of the storm.

Just 20 minutes from the coastline, centraState medical center in Freehold, NJ, a 284-bed teaching hospital in the center of the state, operated in the dark for nearly two days while back-up generators provided power to essential equipment. many hospital employees reported for work even while their own homes were damaged or swept out to sea, according to hospital administrators.

The hospital’s information system went down just as demand for care surged, but administrators say they feel fortunate that the facility was able to get through the storm as well as it did. in the process, they also learned many valuable lessons that will enable them to be better prepared when the next storm hits.

Emergency procedures are put to the test

The hospital started planning during the week before the storm actually hit, explains Linda Geisler, MNED, RN, NEA-BC, FACHE, the hospital’s vice president for patient services. “We had the executive team come together and look at all the resources we would need for the storm in terms of staffing, materials, and equipment,” she says. “We have disaster cabinets on every nursing unit, so we made sure the flashlights, lanterns, batteries, and all of those kinds of things were in working order and ready to be used.”

It was clear that staff were going to have to spend at least one night at the medical center, so administrators developed plans for where people would be bedded throughout the organization. “We got back-up linens because we knew the staff would need that, and we have a fitness center, so [facility managers] agreed to provide shower facilities for our staff,” adds Geisler.

All of these preparations were pulled together through the command center, which was put into place three days before the storm made landfall, explains Daniel Messina, PhD, FACHE, LNHA, centraState Health System’s senior vice president and chief operating officer. The back-up generators were tested to make sure they were in working order, and the management team made sure that all critical equipment was plugged into the hospital’s red emergency outlets, which are connected to the back-up generators.

CentraState Health System is a stand-alone, independent system, but in addition to the hospital, which is a level II emergency facility, it operates a continuing care retirement community, a 123-bed skilled nursing and rehabilitation facility, and a 90-bed assisted living center. consequently, when the power went out within hours of the storm making landfall, health system administrators had to think beyond just the hospital’s concerns. “While we were hustling about with all of the hospital-related priorities, we also had responsibility for the other 600 some odd beds on the post-acute side,” notes Messina.

Demand for care spikes, crucial systems go down

During a typical day, the ED sees 175-180 patients. On the first day of the storm emergency, patient volume spiked to 263, explains Laurie Gambardella, RN, MSN, clinical director of the ED. “One of the main challenges we had was that we had no access to our information system electronically,” she says. “Secondly, our lab downstairs was not functioning optimally.”

The biggest issue was that lab results and other information could no longer be exchanged electronically, so ED administrators developed workaround processes. “We had so many extra people who were helping us throughout the hospital. They were actually transporting the information back and forth,” says Gambardella. “Every time there was a lab result, they would manually write it down and bring it up to the ED and hand it to us.”

The ED also had extra manpower stationed at the entrance to the ED. “They were escorting patients directly back to the care areas where they needed to be,” says Gambardella.

Further, to accommodate the surge of patients who were arriving at the hospital because they could not access their primary care providers, the hospital opened up care areas adjacent to the ED where these patients could be triaged to and cared for by nurse practitioners or physicians who were stationed in these areas.

“One of the populations we saw was elderly people who were just very cold at home. They needed some warmth, so they would come in,” says Gambardella. “Some needed respiratory treatment and they didn’t have electricity, so they came in.”

The ED also saw a high number of young children who were brought in for various reasons, and there was also an uptick in the number of patients coming in with mental health issues such as depression and anxiety. The ED had two nurses and one registration person stationed in the waiting room so that they could monitor the patients who had not yet been seen and make sure that serious problems requiring quick attention were not overlooked.

Emergency department visits increased by about 41% during the hurricane week, admits went up by about 50%, and the number patients sent to observation went up by 450%, says Messina.

Adjacent resources ease stress on the ED

While the hospital did take in some patients from a local nursing home, the biggest impact on the hospital in terms of volume came from patients who simply couldn’t get in to see their regular physicians. “We have seen this happen before, but this is the first time everything happened all at once,” observes Gambardella. “Our computer systems were down, outside physician offices were closed, and people had no access to pharmacies or outside services.”

Messina agrees, noting that with all the electricity down in the region, safety was also a concern for hospital staff that were coming in to work. “It was the perfect storm, not just from a meteorological standpoint, but from an operational standpoint as well,” he says.

To ease pressure on the ED, hospital administrators were able to make use of an adjacent ambulatory campus where the health system has medical offices that it provides to the medical staff. “We do have time share space which we make available to interested physicians and, fortunately, we had some extra capacity, which we were able to offer to local physicians who had no ability to open their own offices” explains Messina.

The health system never had the need to implement this type of arrangement before, but the approach proved useful in this situation, positively impacting patient flow in the ED and timely patient care, explains Messina.

Emergency highlights weaknesses

While administrators give high marks to the way staff performed during the storm emergency, they learned several valuable lessons that they intend to make use of in their emergency plans and drills going forward. For example, Messina wants to put in place additional contingency plans for what will happen in the event that back-up generators fail.

“We check these things on full-load on a regular basis, but equipment does fail,” he says, explaining that one of the hospital’s back-up generators did go down during the storm, impacting the lab and some of the hospital’s support services for a short period of time. In this case, the hospital was able to work around the problem, but messina wants to develop more robust plans to handle this type of situation in the future.

Also slated for further review is what procedures the health system needs to have in place to protect the community in the event of a major disaster like Sandy. messina advises colleagues to consider this issue as well. “What happens when you discharge patients out of the ED and they have no place to go to fill their scripts?” he says.

During the storm emergency, centraState’s internal pharmacy provided 24 hours of medicine to people who had no access to pharmacies in the region. Even when some of the commercial pharmacies began to open, they lacked access to electronic pharmaceutical records. This is just one of the issues disaster planners need to consider when thinking about the community’s vulnerabilities in the event of a large-scale emergency, adds messina.

Crowd control is another problem to consider, notes Cathy Janzekovich, MA, RN-BC, NEA-BC, the health system’s assistant vice president of nursing. “We would have whole families come in with someone because they were cold,” she says. “We would have people coming in to plug in their phones and [other electronic devices], so we made a designated center in our ambulatory building where these people could go to get them out of the ED and away from the patient care areas.”

Communications problems are a key focus for improvement

CentraState had clearly identified red plugs that they could plug ventilators and other essential equipment into to connect these life-saving devices to emergency power, but it is clear now that the hospital could have used a lot more of these plugs. “There are never enough plugs when your power is down and you want to plug in everything,” says Geisler. “Also, we could not keep enough flashlights on site. We would give them to patients, and then the families would take them home so we could never keep enough flashlights on site.”

Further, Geisler notes that there is room for improvement in the way the hospital managed communications without the benefit of email or computers. “It is hard because you have people running around the building trying to communicate with everyone,” she says. “The next time, we want to make sure we have a centralized place for people to report because we pulled people from everywhere to help in the ED. I think we can do better with that next time.”

Gambardella observes that one of the things the ED realized early on during the storm emergency was the value of designating one key point person in each department to handle communications. “When the lab went down, a lot of the doctors and nurses were frantically looking for results and calling the lab, so the lab was inundated with phone calls,” she says. However, once the charge nurse in the ED took over communications with a point person in the lab, retrieval of results was actually expedited, she says. It was an approach that hospital administrators developed in the midst of the storm emergency, but one that ideally could be formalized in a disaster plan.

Prepare for large-scale failures

There is nothing quite as instructive as a real disaster to inform how you prepare for such events and conduct practice drills. And messina says there is no question that the hospital will be doing some things differently from now on. For instance, in the past, the hospital tended to test its contingency systems and disaster preparedness based on a single issue at a time, such as losing electricity or losing water. However, it is now clear that emergency preparations need to take into account the possibility of larger-scale failures.

“One of the things I learned was the importance of testing your systems when multiple events occur simultaneously. I think that is something that we don’t do enough of,” he says. In addition, messina points out that it is important to understand the capabilities of your back-up generators, and to have contingency plans in place that enable you to take rapid action if one of your back-up generators fails.

For instance, messina notes that administrators need to consider what happens if the back-up generator for the hospital’s blood bank goes down and there are blood products that have a very short life span without refrigeration.

Another big issue to contend with is making sure that you have adequate fuel, he says. Fortunately, centraState had contingency arrangements with some local providers, including a snow-removal company that had a big fuel supply on hand and was able to help the hospital out during the storm emergency, when there was a drastic fuel shortage throughout the region.

You have to think about all of these potential scenarios and consider what the impact would be on your various departments and services, explains messina. “Overall, we did well. But [the storm] pointed to the fact that sometimes even though we have contingencies and plans in place for each of our major vulnerabilities, when they come flying at you all at once, it can really stress the system,” he says. “So even if you have contingencies, [a large-scale emergency] can really impact your ability to create a good work-flow or work-around.” n

Sources

  • Laurie Gambardella, RN, MSN, Clinical Director, Emergency Department, CentraState Medical Center, Freehold, NJ. E-mail: LGambardella@centrastate.com.
  • Linda Geisler, MNEd, RN, NEA-BC, FACHE,Vice President, Patient Services, CentraState Medical Center, Freehold, NJ. E-mail: LGeisler@centrastate.com.
  • Cathy Janzekovich, MA, RN-BC, NEA-BC, Assistant Vice President, Nursing, CentraState Medical Center, Freehold, NJ. E-mail: CJanzeko@centrastate.com.
  • Daniel Messina, PhD, FACHE, LNHA, Senior Vice President, Chief Operating Officer, CentraState Health System, Freehold, NJ. E-mail: DMessina@centrastate.com.