Many heroes from these disasters
When a series of four hurricanes hit the coasts of Florida during August and September 2004, it was the worst of times and the best of times, says Lois Holcomb, regional patient access director for Hospital Corporation of America’s (HCA’s) Tampa region. The worst times had to do with evacuating critical care patients, determining how to register and bill patients moved from one facility to another, and anticipating the target of a storm that changed course at the last minute, she notes. (See summary of hurricanes' activity and damage.)
Fear kept some nurses from returning
In some cases, staff who had weathered one hurricane refused to come to work as hospitals prepared for the next one, Holcomb says. "The administration [at one Gulf Coast facility] said, We’re evacuating patients, but we still need people to report to work’; and [staff] just said No.’ They left because they were scared. The hospital couldn’t get nurses to come in."
On the other hand, she points out, "I have so many heroes in this story. A situation like this sometimes brings out the best, which far outweighs the worst. We had nursing staff from a [Florida] east coast facility who got on a bus and came over to the [Gulf Coast] to assist after Charley hit because we couldn’t get enough nurses," Holcomb adds. "HCA made sure that folks who did not have a place to show up for work — or who couldn’t show up because they had lost their home — still got paid. They put together a fund for the whole company to contribute to so that employees who were in need had money to take care of home issues," she notes.
Busloads of staff from the Tampa area went down the coast to Port Charlotte, which sustained a direct hit, to help employees put roofs on their homes, Holcomb says. "Our patient account services employees collected things that staff really needed down there, because the grocery stores were cleaned out and couldn’t open because there was no electricity."
Holcomb rented a large SUV and took needed items to the patient access staff at the affected Port Charlotte facility — Fawcett Memorial Hospital. "They would come in and pick out what they needed. And what was not needed, they would give to the rest of the hospital staff. I also made several trips [later] with carloads," she notes.
On one of those trips, she was accompanied by the patient account services (PAS) CEO and COO, Holcomb explains. "In addition, a truckload of items donated by the PAS staff was delivered to Fawcett by the HCA supply chain."
A change in direction
When Hurricane Charley hit, "we were prepared at the hospital level in terms of a disaster plan, but [not so much] in terms of what occurred during the hurricane," Holcomb notes. Charley was expected to hit Tampa, but instead, the hospitals most affected were those in Port Charlotte, which took a direct hit, and Fort Myers, Holcomb says. As a result, the HCA facility in each of those cities had to be evacuated because of roof damage, she adds.
"As part of disaster planning," Holcomb notes, "patient access staff are prepared to assist in other areas because you don’t expect people to come to the hospital during a hurricane. At Port Charlotte, although they were evacuating, people were not taking [the hurricane threat] seriously, since the storm was forecast to head north. Once they saw the storm was coming to them, people didn’t know where to go and would show up at the hospital."
Prior to that influx, the hospital had been receiving special-needs patients — such as those who require oxygen, she notes. "There are different levels of evacuation, and the first is for special-needs patients and those who live in mobile homes. After that, it’s based on elevation [of homes]."
Emergency plans for pets, too
Because the storm jogged to the right at the last minute, the area had not been fully evacuated, Holcomb adds, and "people showed up at the hospital with family members and animals."
"Usually, facilities anticipate that staff will come to work knowing they may have to stay [for an indefinite time] and will bring family members with them," she says.
Normally, animals aren’t allowed anywhere in the evacuation facility, Holcomb points out. However, there is an increasing awareness on the part of those in charge of evacuations, she says, that people have animals, and they aren’t going to leave their homes without them. Fawcett Memorial, Holcomb notes, "did a dynamic job of being sensitive to that situation, particularly with the elderly."
In fact, the hospital established a pet shelter that started in a supply closet and eventually was moved to an accounting area on the ground floor, says Debbie Elliott, patient access director at Fawcett. "We even had a snake."
During the influx of shelter seekers, Holcomb continues, patient access staff were responsible for identifying those who were walking in, putting their names on a list, noting where they were told to go in the hospital, and taking information on any skills they might have. "Maybe someone was a retired nurse — we would want to know that," she says, adding that others might be needed as translators or to help transport patients.
Some of the arrivals were planned, as when physicians called and said they had special-needs patients who needed to come over, Holcomb says. "The nursing homes were emptying out."
Once the storm hit, and the roof and water problems began, patients were moved from upper to lower floors, she says. Eventually, all of the hospitals in Port Charlotte — including two non-HCA facilities — had to be evacuated, she adds. "HCA hospitals to the north, in Sarasota, Englewood, Bradenton, and even as far north as St. Petersburg, had to prepare to take those patients."
"It happened on Friday, so the critical care patients had to go out that night, and Saturday and Sunday the others were taken," Holcomb explains. During this period, communication was problematic, with cell phones not working and limited systems availability, she notes. "HCA’s main computer hub for Florida is in Orlando, and Charley went right through Orlando. This created periodic system outages."
Meanwhile, Holcomb says, "patient access staff were assisting with patient care to the degree that they could. The hospital had removed patients from the facility itself and had set up tents. So staff were comforting patients and trying to assist family members."
Fawcett Memorial was able to keep the emergency department open for limited services throughout and after the storm, she says; but if there were serious injuries, patients had to be put in an ambulance and sent elsewhere.
Getting access to patient data
From an operational standpoint, Holcomb points out, the optimum scenario for hospitals in shared environments, such as the HCA system, is when facilities have access to each another’s database during an emergency situation. She emphasizes the importance, however, of being extremely conscious of Health Insurance Portability and Accountability Act (HIPAA) privacy regulations if such access is granted.
At HCA, access to another facility’s data is given sparingly, and only to a person at the director or supervisor level, Holcomb adds. "HIPAA requires that we only have the information we need to know."
Preregistration saved time
For example, at Doctors Hospital in Sarasota, which received patients that were being evacuated from Fawcett Memorial, the patient access director — after making the request to HCA’s regional IS department — got limited access to Fawcett’s database, she explains.
The director then accessed only the data on the patients Doctors Hospital was receiving and printed the demographic and insurance information for registrars, who prepared an account in the receiving hospital’s system, Holcomb points out. "When the patient arrived by ambulance and a room number was assigned, the registrar could simply activate the account, and they were ready to go," she says. "Nurses could start the ordering process." In effect, those evacuated patients were preregistered to the receiving hospital just like any scheduled patient, Holcomb notes. "That was a huge advantage."
Conversely, in cases where a hospital receiving evacuated patients was not able to gain access to the patients’ records, she adds, "we had to rely on the transferring facility to send us the information we would need. Sometimes, it came with the patient. Sometimes, we got very little."
Later, on the back end, access staff had to determine, for billing purposes, how to record the patient’s status — whether inpatient, outpatient, or observation — Holcomb says, depending on whether the patients would go back to the original facility or stay at the one to which they had been evacuated. "If patients return to the facility [from which] they were transferred, then that facility bills [the payer] for the entire stay; and the one where they were housed temporarily bills that facility," she explains.
That didn’t happen during Charley, Holcomb adds, because Fawcett had to close. And even when it reopened, the facility could accommodate only a limited number of patients, so it didn’t take back the evacuated patients. Instead, staff placed all the accounts in observation status at the receiving facility, keeping them as outpatients until it could be determined how the billing should be done and then changed them to inpatients, she explains. "So there was a lot of cleanup."
Using hurricane experience to plan ahead
The experience with Charley better prepared the access staff for hurricanes Ivan, Jeanne, and Frances, Holcomb says. "Before, we never even thought about billing issues on the back end [as part of hurricane preparedness]. You definitely need to be aware of the billing regulations — by payer — as to these disaster situations. "Typically, commercial payers follow the same billing standards as Medicare," she continues.
"We worked closely with our contracted managed care payers to address any specific issues. Managed care payers waived the 24-hour notice of admission requirement as a result of the hurricanes," Holcomb explains.
The Tampa HCA patient accounts service center handles 22 facilities in the state of Florida, and all are on the same system, Holcomb says, which allows the organization to more easily share staff — as well as patient data — throughout the different facilities. Another PAS center in the state handles 19 facilities, she notes.
Staff helped out at their sister HCA facilities not only during the fallout from Hurricane Charley on the Gulf Coast, she points out, but also when the east coast was hit by Frances and Jeanne. "Those hurricanes were so long that the employees there were exhausted," Holcomb says. "After the storms were over, facilities that weren’t hit as badly — including some in Miami and Fort Lauderdale — sent staff up to Port St. Lucie and some of the other hospitals that were hit harder," she adds.
After Charley, Holcomb adds, Holcomb sent staff from the Tampa area down to Port Charlotte. "It was the same system, so they already knew how to register patients." Nurses were shipped all over the state as well, she says, including to the Panhandle area, which was hit by Hurricane Ivan. "Wherever the need was, HCA was able to fill some of those needs from within its own organization."
After the hurricane, notes Elliott, a team for each hospital department sat down to evaluate the facility’s handling of the crisis. She says there is little she would do differently, giving high marks to the administrative staff. "Our CEO kept us informed constantly," Elliott says. "Beginning a week prior [to the hurricane] he kept us up to date on everything, and it was up to us to relay the information back to our staff."
A day-care center, staffed by patient access employees, "was probably the best thing we did," she adds. "We had to have nurses here, so we kept it up and running for about two weeks [to provide care for their children]."
Another thing that worked very well, Elliott continues, was the intake of shelter seekers, including the families of physicians, staff, and patients. "We placed an armband on all of them and kept a running list of adults and a separate list of the children. Because we had the day-care center, we needed to make sure which child belonged with which parent."
The practice of listing people’s skill sets came in handy, she notes, when one of the visitors started having chest pains. "We found the doctor real quick."
With both hurricanes — Charley, and in anticipation of Ivan — staff made copies of all the medical records, Elliott says. "We set up a pool of employees who were here seeking shelter, and they did nothing but make copies of records. Any patients who were transferred out [took] a medical record went with them. That was also helpful [for] the receiving facility."
To keep a close eye on who was where in the hospital, she says, Elliott did a house census every 15 or 20 minutes prior to the first hurricane. "We would periodically go to each floor and make sure that Betty Jo was really in Room 204, Bed 1, as our report said."
One thing she wished she had been better prepared for, Elliott notes, was when the ED took a big hit that destroyed the doors. "We had to evacuate and go to the second floor, and we weren’t prepared to do that. We were scrambling to find printers, computers on wheels, etc."
In hindsight, she adds, "once we got confirmation the hurricane was coming close, we should have either evacuated [the emergency department] or started to get paperwork in place. We could have left a registrar downstairs until the last minute and taken some of the equipment upstairs."
Access staff served as runners, helping to fax and make copies of information being sent to other facilities, Elliott explains. "On the second floor, where we had a command center set up, I relied on my staff to go around and help keep people calm."
The day after the hurricane, access employees helped coordinate the arrival and departure of ambulances, she adds. "It was very chaotic. By 8 in the morning on Saturday, we had 36 ambulances lined up in our driveway. There was a person stationed at the door to greet them and confirm where they were going," Elliott continues. "We were in constant communication with case management and knew at all times which patient was going where."
Another lesson learned through experience was the importance of — if a facility is damaged and able to be open only in limited capacity — looking at the room and board master files to make sure they are set up appropriately in terms of charging for patient stays, she points out. Because of the different price categories — rehab beds are charged at a different level than intensive care unit beds, for example — changes have to be made when the beds are used for a different type of patient, Elliott adds.
Balancing different needs
Holcomb says one of the most memorable aspects of the hurricane experience involved the human relations challenges. "My patient access directors did a really good job of trying to balance the needs of their employees — being sensitive to what they were going through personally, while meeting the staffing needs of the facility," she notes. "I had several directors who were there 24-hours a day until the fallout from the storm was under control. They never left the hospital."
While each CEO handled things a little differently, Holcomb adds, "the hospitals that really rallied were those that allowed families to come in and even bring their animals. "That human touch goes a long way, and it isn’t forgotten after the storm. Every time I go down to Fawcett, they’re still saying thank-you," she recalls. "We all have a job to do and during a disaster situation, that’s first and foremost. But employees also have their needs and a family they’re worried about.
"It’s one thing to ride out a storm at the hospital, and another thing to then go home and see if you have a home," Holcomb concludes.
(Editor’s note: Lois Holcomb can be reached by e-mail at Lois.Holcomb@HCAHealthcare.com.)