Lessons learned from Hurricane Katrina: EDs share their best disaster strategies

Pinpoint areas to improve by constantly asking, What if?’

You may have planned for an influx of injured patients and fine-tuned your decontamination process. But what if your own hospital is flooded, the ED has to be evacuated, and some of your patients are armed and dangerous, with no law enforcement in sight?

That’s the situation some ED nurses faced in Louisiana, Mississippi, and Alabama during the aftermath of Hurricane Katrina, and it was a scenario none had addressed in disaster drills. EDs across the country are now asking, "Could we have gotten through it?"

The catastrophic results of the hurricane are incomprehensible, notes Sharon S. Cohen, RN, MSN, CEN, CCRN, clinical nurse specialist for North Broward Hospital District in Fort Lauderdale, FL. "To me, it equates to the tsunami," she says. "Every disaster presents learning opportunities, and we’re going to have to learn from this."

Constantly thinking of "what-if" scenarios and incorporating these into disaster drills is of utmost importance, says Cohen. Having a plan in writing means nothing, she says. "Practicing it is the only way to find opportunities to improve," she says. "Every disaster is going to be different, so the more scenarios you practice, the more prepared you are."

To significantly improve your ED’s preparedness, do the following:

Don’t get caught short-staffed.

Previously, North Broward Medical Center divided ED nurses into two groups: those who would work before and during a storm, and those who would work after. This caused a problem during 2004’s Hurricane Francis, when the dangerous storm remained overhead for an entire day.

"We discovered that we didn’t have enough staff for the before/during phase, which was a huge stress on the 12 nurses we did have," recalls Philip Ragusa, RN, regional manager of emergency services. "They ended up having to work for 36 hours straight."

Now, the ED has a day and night shift for both the "before/during" and "after" groups. "For Katrina, we implemented our disaster mode at 3 p.m., so everybody already at work went home except the before/during day shift, who worked 3 p.m. to 7 a.m., and the before/during night shift who worked 7 a.m. to 7 p.m.," he reports.

Drill on an off shift.

The Joint Commission on Accreditation of Healthcare Organizations requires that one of your disaster drills be held during an off shift. "You can have a disaster drill go smooth as silk, but how well prepared will your staff be at 9 p.m. on a Saturday?" asks Ragusa. "The amount of resources available during the off shift, both in terms of manpower and accessible supplies, is very different."

Ask nurses for input.

Immediately after a drill is held, or as soon as possible after an actual disaster, North Broward’s ED has a post-conference to solicit feedback on what could have been done better, says Ragusa.

"This is a critical component that people often forget about. The best lessons learned come from the people who work at the bedside with the patient," says Cohen, adding that critiques should be done right away. "It may be midnight and staff will want to go home, but if you wait 48 hours, people start forgetting some of the details."

After you obtain feedback, set a timeline of 36 hours to write an "after-action" report listing needed changes, she recommends.

When a disaster drill is scheduled, two ED staff members are asked to be evaluators and are paid overtime for this, says Cohen. "They know what the normal process of the ED is, so they can tell you where the bottlenecks are," she says. "It may be as simple as changing the direction a door opens."

Disaster plans should be revised continually, based on lessons learned from your own drills or actual disasters, says Jeanne Eckes-Roper, RN, director of emergency preparedness for the North Broward Hospital District. They also look to other institutions and their lessons learned, to identify opportunities for them to improve, Eckes-Roper says. "Disaster preparedness is a dynamic process and always will be," she says. "It has to be fluid."

Include decontamination.

Even natural disasters can have hazardous components, such as gas, waste products or chemicals, notes Cohen. In New Orleans, there were biohazards floating in the water, she says. "You need always to be thinking, Do patients need to be deconned? Do we need to take care of exposure in addition to the injury?’"

A recent disaster drill scenario at North Broward involved a bomb exploding on a train coming from Miami releasing an unknown chemical, so all patients had to be decontaminated. "We included one person with a pre-existing debilitating injury who also had to be decontaminated," recalls Ragusa.

Despite the fact that pre-hospital personnel were told to send all "walking wounded" patients to surrounding hospitals for the drill, there still were a number of patients who walked into the ED themselves, Ragusa notes. "Many people will drive in themselves and need decontamination, so we completely locked down the hospital."

Identify alternate care sites.

If your ED is filled to capacity, you may need to care for patients with minor illnesses or injuries in areas such as auditoriums, cafeterias, infusion centers, or outpatient surgery areas, says Eckes-Roper. "As part of their plan, each of our hospitals has identified alternate treatment sites outside their EDs."

During disaster, Cohen’s ED uses an ambulatory clinic as a "mini-ED." "It’s not meant for stroke or heart attacks, but we can do wound checks and the things that don’t need to be clogging up EDs," she says.

Update call lists.

An up-to-date personnel callback roster in the ED will avoid delays when staff members need to come in immediately, and you should review callback lists periodically, says Eckes-Roper. "In addition, every time a storm threatens, the managers are asked to make sure it is up to date," she says.

Whether you contact staff by e-mail, telephones, cell phones, or pagers, you should update your list at least quarterly, says Cohen. "The best way to do this is to drill your callback procedure, for example, the first Monday of every third month," she says. "The more often you update the list, the better prepared you’ll be when you need to call in staff during an incident or disaster."

Have backup communication plans.

The No. 1 failure of most critical incidents is communication, notes Cohen. "If you are basing your communication on a singular plan, you’re going to end up getting caught," she says. "Your backup plan has to have a backup plan."

For example, you need to plan for internal phones being down and your dispatch down, Cohen adds.

Cohen’s ED relies on land lines, wireless phones, and two-way radios — and all of these would have failed during Katrina. "The New Orleans EDs lost every known form of communication," Cohen says. "They lost cell phone towers, pretty much anything." With a Category 5 storm, satellite phones are about the only communications tool that works, she adds.

Ham radios also are a possibility when all else fails, says Cohen. "Anytime our mass casualty incident plan is activated, part of our plan is to call one of our volunteers who is a ham radio operator," she notes.

Sources

For more information on disaster preparedness, contact:

  • Sharon S. Cohen, RN, MSN,CEN, CCRN, Clinical Nurse Specialist, Emergency Preparedness, North Broward Hospital District, 303 S.E. 17th St., Fort Lauderdale, FL 33316. Telephone: (954) 355-5109. Fax: (954) 468-5270. E-mail: sscohen@nbhd.org.
  • Jeanne Eckes-Roper, RN, Director of Emergency Preparedness, North Broward Hospital District, 303 S.E. 17th St., Fort Lauderdale, FL 33316. Telephone: (954) 712-3931. E-mail: JECKES@nbhd.org.
  • Philip Ragusa, RN, MBA, Regional Manager of Emergency Services, North Broward Medical Center, 201 E. Sample Road, Deerfield Beach, FL 33064. Telephone: (954) 786-6866. E-mail: pragusa@nbhd.org.