Disaster preparedness: Lessons learned from the response to Hurricane Katrina
JCAHO wants to see evidence of planning for large-scale catastrophes
Your recent disaster drills may have prepared you for scenarios such as local school bus accidents, an explosion at a nearby plant, or chemical spills at a factory.
But what about a disaster of epic proportions that leaves your hospital structurally damaged, with no power for days? Or a bioterrorism attack that paralyzes every community resource in the surrounding area?
The lesson to learn from Hurricane Katrina: Think big. When doing a hazards vulnerability analysis to determine which disasters are most likely to strike, your organization must consider major catastrophes and large-scale events, says Robert Wise, MD, vice president of the division of standards and survey methods for the Joint Commission on Accreditation of Healthcare Organizations.
"I think organizations have been timid in being clear about the hazards that might occur to them," he says. "Because if, in fact, it’s decided that they have to prepare for a significant hazard, then obviously there are potentially significant expenses associated with that."
Typically, the hazards most frequently prepared for are those that have already occurred, says Wise. "That makes sense, but at the same time, the catastrophic ones also have to be at least considered," he says.
Every disaster presents a learning opportunity, says Wise, who recently visited the Gulf region to meet with affected health care organizations. "We typically go to the area about six or eight weeks after the disaster, when things have calmed down, and will do this with New Orleans and Mississippi. But it is way too premature to seek lessons learned at this point," he says.
One of the biggest lessons is already readily apparent, however: The more planning an organization does, the better. "All the resources invested in planning will be paid for many times over when the actual disaster occurs," says Jonathan Weisul, MD, vice president of medical affairs for Alexandria, LA-based Christus St. Frances Cabrini Hospital. Weisul is responsible for JCAHO compliance for Christus Health’s Central Louisiana region. "This was a response of unprecedented dimensions, and the follow-up and after action will be created as we go."
Although the hospital wasn’t directly affected by Katrina, over several days 700 patients were triaged and hundreds were hospitalized. At one point, the hospital’s Mass Casualty Incident plan was activated after buses with 100 patients arrived with less than 30 minutes notice. "In that experience, the disaster plan worked extremely well. We were able to triage and place the patients within four hours. That included one fatality that died on the way, but other adverse outcomes could have occurred if the plan hadn’t worked as well."
"I don’t think quality has been addressed until recently in emergency management," says Victor H. Kennedy, MPH, CIH, director and health care system safety officer at UCLA Medical Center in Los Angeles. "The planning and drill efforts didn’t go beyond the initial response."
That is changing now, he says, pointing to the Joint Commission’s emergency management standards, which state that they reflect "the application of continuous quality improvement methods to the performance of emergency management preparation."
New emphasis on quality
"In the new JCAHO standards, there is a good bit of talk about quality. JCAHO has given justification" to a new emphasis on quality, he says.
This means that organizations will need to "push the envelope" when evaluating drills to ensure that quality has been assessed and maintained, says Kennedy. Drills typically end after three or four hours, but the window of time for evaluation should be expanded to measure the quality of care given to patients, he argues.
"We typically don’t talk about the degree of quality care we provide to victims. It is easier to talk about mobilization and logistics — whether you got the lights on — than quality."
Ask these two questions after drills, he recommends: How effective was your response? Did you meet your overall objective of continuing to care for patients, and responding to the health care needs of the community?
"We have been discussing this here," Kennedy says. "First, you need to include individuals who are used to measuring those kinds of outcomes, including quality managers."
One possibility is that the first part of a drill could assess the initial response, while a second part could assess follow-up and quality issues, he suggests. "The earthquake happens, you respond, then you take a break and pretend it’s two days later," Kennedy says. "We would follow up with the patients as we do our normal patients. We have a mechanism for that during normal operations, but do we have a mechanism to do that during a disaster?"
He points to the Joint Commission’s four required elements for an emergency management plan: Preparedness, mitigation, response, and recovery. "Following up is part of recovery and is only now getting attention in health care," he says.
"In the past, disaster planning was done mainly to maintain accreditation and meet JCAHO standards," says Weisul.
That is no longer the case, as organizations have made disaster planning a priority and allocated significant resources for drills and planning exercises, says Kennedy. "If something happens, it’s not going to be the safety guy in front of the news media, it’s going to be the CEO," he adds.
Look outside your organization
However, many organizations still don’t participate in disaster planning on a communitywide level, says Wise. "That is one area that continues to be difficult, so we continue to emphasize it," he says. "We are strongly urging — in fact, there is an expectation — that hospitals reach out to the community to find out the role they should be playing."
"If the community is hit by something major and there is no electricity or water or sewage — to have a single hospital prepare for that without having its assets integrated into the overall community plan is not going to make sense," he says.
Participate in community drills, which tend to be tabletops, and invite community planners to your drills, Wise recommends. "It certainly makes sense to invite the community in. We often find, though, that they get invited to so many places they may be more reticent to get involved with individual drills. The expectation is that the hospital gets involved in the community drills."
Organizations can do this by committing their personnel, time, and resources to participate, with involvement of quality leaders, says Weisul. "Participate in the network and establish personal relationships, which are crucial in the time of a disaster," he recommends.
JCAHO surveyors will be asking, "Do you know the names of the emergency management people in the community? Are you participating in meetings? Are you aware of your role in a disaster and how communication will occur?
Use large-scale approach
"These are the types of questions that one would want to be able to answer," says Wise. "If you can’t answer those, then you haven’t done adequate planning. The time to start exchanging business cards is not at the time of the disaster."
When doing your hazard vulnerability analysis, take into account that other resources in your community may be affected, as with the 9/11 terrorist attacks and Hurricane Katrina. "Over the last several years, we have seen some pretty significant disasters, including the loss of electricity in the Northeast and the hurricanes in Florida last year," Wise says. "We have now seen that organizations may in fact be on their own for long periods of time."
Disaster drills are typically geared toward a short period of time, but your organization may need to stand alone for several days, so you must address emergency power, water, sewage, and personnel issues, says Wise. "To be able to sustain an organization for several days without any outside help and build that kind of infrastructure, is actually quite expensive," he says. "That’s why you need to sit down with the community to figure out which medical resources are going to be able to stay up and running, and if organizations need to evacuate, where they would go."
After each drill, an after-action analysis should be done to identify weaknesses and vulnerable areas, says Weisul. "You need to keep asking, What if? What if the backup power went down? What if patients arrive with no notice and helicopters were landing without any contact?" he asks.
At UCLA, every drill generates a written critique and detailed action plan given to the disaster committee, which is chaired by a physician. "It is part of the medical staff executive committee, which gives it a lot more power and makes sure the action plan stays on the agenda until the issues are resolved," says Kennedy. "Then we test them again to see if we actually did fix them."
Identifying backup plans for communication is essential, says Weisul. "Communication during a disaster is crucial," he adds. "One of the difficulties of a true disaster is that information is inadequate or changes by the moment."
During Katrina, cell phones weren’t working since the system was quickly overwhelmed. As a result, St. Frances Cabrini developed plans to use two-way radios as its primary form of communication during disasters. "The ability to communicate with the affected hospitals in New Orleans was reduced to ham radios," adds Weisul. "Hospitals should consider having access to ham radio operators and equipment during a disaster scenario."
During Katrina, an incident command center was established early on, allowing the organization to handle internal and external communications through one central source, acquire and access resources, and participate in the statewide response to the disaster.
According to Weisul, "An incident command center should be a crucial part of disaster planning and drills, because it will become the hub of all communications."
Katrina underscores the need to incorporate evacuation scenarios into your disaster drills. "It does point out to hospitals the need to truly identify and test how you are going to evacuate patients," Kennedy says. "Not just how to move them, but once you get them where they are going, how are you going to continue to provide for their care?"
During a recent drill, the organization used the scenario of a fire down the hall from the operating rooms, done after hours. "We put patient volunteers in each of our 23 ORs and pretended they had five minutes to leave," he says.
During other drills, the organization has practiced moving patients from one wing to another and relocating psychiatric patients. "We try to have a patient movement element to each of our drills," says Kennedy.
In addition, there may be two or more steps involved in moving patients during a disaster, says Kennedy. "You don’t just move them from their point of origin to where care will be provided. You may be moving them outside of the immediately dangerous area, then from that staging area to their final destination," he says. "So there may be incremental steps to evacuation."
The organization’s disaster plan was updated to address this scenario, by identifying specific departments that will formulate a plan for moving patients at a moment’s notice if needed, including bed control, nursing, engineering, central supply, and respiratory therapy. "That group comes together and within five to 10 minutes, they will give the plan to the incident commander about how patients will be moved and where," says Kennedy.
If you know a storm is coming, as many patients as possible should be discharged, says Jeanne Eckes-Roper, RN, director of emergency preparedness for the North Broward (FL) Hospital District. If an evacuation is going to occur, the hospital should make copies of all medical records and be prepared to send all records, films, medications, and anything else needed for patient care to the receiving facility, she advises.
"Appropriate family notifications need to be done in advance of any evacuation, if possible," adds Eckes-Roper. "Patient tracking during evacuation will be a critical key for families and facilities."
Patient tracking is a concern during any disaster, even if evacuation is not required. After multiple victims were brought to the hospital after a motor vehicle crash, Kennedy realized that one patient had four identifiers: a triage number given in the field, a patient identification number assigned upon arrival to the ED, and was referred to as "the boy with the head injury" and "boy with the blue jacket."
"We got together with quality management and said, we can’t have a patient with four identifiers, especially if blood or X-ray are needed," says Kennedy. "Now, when a patient comes in, they get an identifier that cross-references them wherever they go."
[For more information, contact:
- Jeanne Eckes-Roper, RN, Director of Emergency Preparedness, North Broward Hospital District, 303 SE 17th St., Fort Lauderdale, FL 33316. E-mail: JECKES@nbhd.org.
- Victor H. Kennedy, MPH, CIH, Director, Healthcare System Safety Officer, UCLA Safety Office, 200 UCLA Medical Plaza, Suite 202, Los Angeles, CA 90095-6926. Telephone: (310) 825-4012. E-mail: VKennedy@mednet.ucla.edu.
- Jonathan Weisul, MD, Vice President of Medical Affairs, Christus St. Frances Cabrini Hospital, 3300 Masonic Drive, Alexandria, LA 71301. Telephone: (318) 561-4135. E-mail: email@example.com.]