Disaster response strategies gleaned from 9-11 experience

Four planning phases identified

The traumatic events of Sept. 11, 2001, now seared into the national consciousness, were particularly up close and personal for Michael Friedberg, FACHE, CHAM, who was on his way to work at Jersey City Medical Center, across the river from the World Trade Center, when the hijacked planes hit the towers.

"As many people have told you, it was a beautiful fall day," recalls Friedberg, then corporate director of patient access for Liberty Health Care System. "We had a golf outing the day before."

Forty-five minutes after the planes hit, Friedberg had just stepped outside the medical center and saw the second building collapse, he says. "I saw and heard it live. It was like a movie. I heard a rumbling, saw it teeter, and then it started to come down."

Friedberg's experience that day constituted a quick course in handling the patient access implications of a disaster he describes as truly unimaginable.

"On Sept. 10, 2001, if you and I were having a conversation and I told you that two planes would be hijacked and purposefully flown into the World Trade Center, starting a massive fire, you might have believed that," says Friedberg, who is now director, patient access services, at Armanti Financial Services in Bloomfield, NJ. "But if I had said those buildings would subsequently crumble to the ground, you would have locked me up."

There were many lessons learned that day, he adds, and a number of quickly made decisions that turned out to be exactly right. In retrospect, Friedberg identified four phases of disaster planning, which he explains below:

1. Pre-event planning (the routine work everybody does on a regular basis).

The first questions to ask, Friedberg suggests, go something like this: Do you have a plan? Is the plan realistic or was it created in 1980? We live in a different world now and if your plan is more than five years old, you need to take a look at it.

Perhaps most importantly, he asks, does your plan contemplate the complete loss of communication?

As regards 9-11, Friedberg explains, the cell phone towers and the emergency medical service (EMS) radio for his hospitals' EMS service were on top of the World Trade Center. In addition, he says, television and radio stations in the vicinity were down, computers were down, and the main telephone switch building, located several blocks from the site, was out of service.

"You need to think, 'What would I do if I couldn't use the phone or the Internet, if all the beepers went down? What if the computer system gets knocked out? All hospitals have generators, but what if communication is interrupted between you and your main server?

After the 9-11 attack, New York City was closed to all traffic, Friedberg notes. "You could not get on or off the island of Manhattan. There was no vehicular traffic, so no supplies [being delivered]. What I want to emphasize is that we've all had multiple-casualty incidents, but think what it would be like if in the next hour, your facility was going to get 1,000 patients?"

With tens of thousands of people working in the World Trade Center, the potential for patients was huge, he points out, although it turned out that most of those impacted by the attack either got away or were killed.

Not knowing how long an event will last, Friedberg says, patient access directors dealing with a disaster must think about immediate issues while also considering the future.

"Designate roles for all management staff, and consider what you will do if somebody is not there," he advises. "On that day, the [access] director for Jersey City was on vacation and by the time we realized [he should come in], he couldn't get there. My number two person, the assistant corporate director, was on maternity leave. Otherwise, we could have split up [duties]."

Procedures for communication, bed placement, bed overflow, alternate registration sites, and coordination with nursing should be established, Friedberg adds, as well as for getting supplies and arranging accommodations for patients' families.

2. Before the first patient arrives.

This is the point "where you know there's been a disaster and you know patients are coming and that's all you know," he says. "Estimate event magnitude. Are we getting 50 patients or 500 patients? Forget about whether you can handle them or not. That doesn't matter — you're going to get them."

Friedberg made the decision to consolidate access staff by holding over the night shift, he notes. "I did not call in the 3 p.m. to 11 p.m. shift because I was worried [the emergency situation] would go more than eight hours and I needed reliable people to cover the next shift. People burn out at some point."

The hospital canceled all elective procedures, designated acute and non-acute treatment areas and closed the emergency department, Friedberg says. "We were in an older building that had an auditorium and we made that a non-acute fast-track area. We were able to pull computers to the front of it to register patients."

"You also need to designate a waiting area for non-acute treat-and-release patients," he adds.

That area was needed to accommodate, for example, individuals who were treated for minor injuries and released, but who couldn't yet get to their homes, Friedberg says. "For somebody who worked at the World Trade Center and lived on Long Island, being in Jersey City put them 40 or 50 miles from home."

3. During the event.

One of the most useful spur-of-the-moment decisions Friedberg made on 9-11, he recalls, was to use the hospital's downtime numbers — a separate sequence of account numbers typically used when a facility's computer system is down — for all patients whose treatment was related to the attack. (See related story, below.)

Good documentation key in disaster recovery process

Reimbursement tied to record-keeping

In the event of a disaster, advises Michael Friedberg, FACHE, CHAM, director, patient access services at Armanti Financial Services in Bloomfield, NJ, maintain complete and accurate records.

Careful documentation of all the patients treated at Jersey City Medical Center as a result of the Sept. 11, 2001, attack on the World Trade Center, including using the hospital's downtime account numbers for those individuals, helped the hospital recoup all of its disaster-related expenses, notes Friedberg, who at the time was corporate director of patient access for Liberty Health Care System, the hospital's parent company.

"We had the foresight, thankfully, to do patient tracking, expense tracking, to use special codes for that," he says. "We realized the feds were going to pay for it in time to capture what we needed."

While most hospitals in New Jersey received 20 cents on the dollar for disaster-related expenditures, Friedberg adds, Jersey City Medical Center got 100% reimbursement.

"It was easy to identify within the system that those patients were related to the incident," Friedberg says. "We closed the ED, but we did have a patient come in who was very sick. That child got a regular account number and every person from the Trade Center got a [downtime] number beginning with 888."

It also was important, he says, for the hospital to provide a "staff decompression area" where employees could take a moment of respite from dealing with the tragedy.

"Everyone in the New York metropolitan area knew someone who worked at the World Trade Center," Friedberg points out. "Having to focus on doing your job while the worst tragedy since Pearl Harbor is going on in your backyard is one of those things you don't think about."

The role of a patient access manager/director during a disaster is to be troubleshooter and information distributor, he notes. "I found it very important to find some positive news to give out. For example, it was election day, so there were not as many people in the buildings as there would have been on a normal day."

Rumor control — difficult enough in a hospital when there's not a disaster — is another facet of the job, Friedberg says. One notable account of the 9-11 tragedy came from a police lieutenant who came into the hospital's ED, he adds. "He told us, 'We have four planes down — two at the World Trade Center, one at the Pentagon, and one in Pennsylvania' — but he also said there were four more planes out there, targets unknown.

"So people were wondering what could be next — the White House, the Capitol? It helps to communicate to staff as often as possible what is actually happening."

Friedberg also saw it as his duty to be the advocate and watchdog for access staff. "I had to make sure [employees] still had the ability to do their job." He suggests that the manager/director makes it a point to float between the acute and the minor treatment areas. "You want to make sure all the staff are OK, that everything is going smoothly."

The access supervisor can play a vital role in streamlining operations during a disaster, he suggests, by being responsible for employee placement and acting as a catalyst for patient throughput.

"The supervisor should make sure staff are focused on throughput, not talking to the patients about what happened to them," Friedberg advises. "I know it sounds strange, but the supervisor needs to be the cheerleader, [saying], 'Come on, we can do this, we are trained for this.'"

Supervisors also should serve as management's "eyes and ears," he says. "It was one of my supervisors who took me aside and said, 'So-and-so is freaking out,' and that was the person I pulled out of the registration line."

One of the procedures in place was for registrars to stand in a line and, as patients walked up, for an employee to accompany each person to a room and ask for demographic information, he says. "[Employees] got upset and we had to pull them out of line and calm them down. We told them to take a few minutes and then come back and do their job."

Once the patient information was obtained, Friedberg continues, staff would bring it to the person designated to do data entry — the fastest and most accurate registrar. "We didn't worry so much about insurance, but we tried to get demographics and employer information. We didn't know who was going to pay for care, but at that point it didn't matter."

In the midst of dealing with issues related to care and staffing, he notes, queries were coming in regarding patient tracking and identification.

"Every government agency wanted information," Friedberg recalls. "The fire and police departments were looking for staff; the state and the city of New York were looking for statistics so they could figure out what resources were needed. The state of New Jersey had to figure out how to provide resources to assist New York, but not at the expense of the care of the citizens of New Jersey."

4. After the event.

Returning to normal operations took time, he says. In addition to the calls from government agencies, which went on for more than a week, Friedberg notes, the impact on the surrounding community had to be considered

"I realized that the next day we would be inundated with phone calls and people showing up looking for loved ones," he says. "Since access ends up doing everything, I knew the telephone operators were going to send those calls to us anyway, so I volunteered us for the job."

"That was a huge thing we learned," Friedberg recalls. "You've got to consider, 'What are people going to do?'"

Although his instincts told him many people would come to the hospital looking for information, he notes, there was some resistance to the idea from the director of another department, who predicted that everyone would go to Manhattan.

The call center he created at Jersey City Medical Center became the call center for the state of New Jersey, Friedberg says. "We set up a room with computers and coordinated with the behavioral health group, which had counselors on hand so anyone who needed grief counseling or was overwhelmed had someone there to handle their concerns.

"In four days, post-9-11, we operated 24 hours a day and answered 5,000 phone calls," he notes. "In addition, we had more than 300 people come to the hospital looking for loved ones. We were the ones who had to look and say, 'I'm sorry, that person is not on the list.'"

There also were people who drove from as far as 1,000 miles away and showed up at the hospital to see if they could be of assistance, Friedberg recalls. "One guy was a dentist. He said, 'I have skills. How can I help?'"

Among hospital personnel, he says, "for the most part, all departmental barriers, all rivalries — including the idea that patient access is not an important part of the overall process — went out the window during this event. Everybody worked together."

(Editor's note: Michael Friedberg can be reached at mfriedberg@armanti.com.)

Contamination threat should be considered

'How do you protect staff?'

While there was no real contamination threat in relation to the World Trade Center attack, it's certainly a possibility that hospital leaders should keep in mind during preparation of a disaster plan, says Michael Friedberg, CHAM, FACHE, director, patient access services at Armanti Financial Services in Bloomfield, NJ.

There was a debate over whether debris from the collapsed buildings might have been toxic to those who came in contact with it, "but it didn't turn out to be an issue," notes Friedberg, who at the time was corporate director of patient access for a health care system with a facility located across the river in Jersey City, NJ.

"However, [contamination] is something you would want to consider in thinking about the possibility of a similar incident," he says. "What do you do with everything that is contaminated? What if there is a nuclear attack and the first person comes in and contaminates the emergency department? How do you protect your staff?"

A study published recently in Disaster Medicine and Public Health Preparedness suggests training more medical personnel in burn care, pre-positioning narcotics for burn treatment, and establishing systems to track displaced citizens, who will need food, shelter, and basic medical care.

"It is imperative that cities consider the catastrophic health consequences of a nuclear attack and create plans that will account for such an extreme challenge," said lead author Cham Dallas, director of the Institute for Health Management and Mass Destruction Defense at the University of Georgia.

Using prediction models, the study estimates a 550-kiloton nuclear weapon — more than 40 times the power of the Hiroshima nuclear bomb — would result in 786,000 burn victims in Los Angeles and 257,579 in Houston, of which fewer than one-quarter would survive.

Funding cycle discourages disaster planning

The federal government spends less than $5 per person annually to help health systems and agencies prepare for a disaster, according to a recent report from PricewaterhouseCoopers.

"An annual funding cycle discourages long-term planning or development of a sustainable response infrastructure, and many hospital executives believe that the administrative costs of applying for funding are overly burdensome for the level of funding received," the report adds.

Based on surveys and interviews with stakeholders and other studies and data, the authors identify gaps in U.S. health system preparedness and suggest strategies to improve readiness at the organizational, community, and societal levels. Among other actions, the report suggests hospitals identify how they will free up capacity in a disaster, recycle supplies to extend limited quantities, and ration resources to care for those most likely to survive.