As at Mass General, there's been a much greater emphasis on practicing. The U.S. Department of Health and Human Services is currently working with the RAND Corp. to develop a simple, low-cost approach to "no-notice" drills, which have been used for years in Israel. A hospital agrees to a one-week window, within which a team of four drill conductors – RAND folks now, eventually colleagues from another hospital – can show up at any time. Within 90 minutes, hospitals complete a set of critical actions, including securing the facility, clearing patients from the ER and creating enough capacity to handle a large surge of injuries. Art Kellermann, an emergency physician and RAND analyst, calls the approach, which is still in development, a voluntary "stress test" for hospitals.
Besides individual hospitals that are ready for anything, what's needed are coalitions of health care facilities, first responders and other public and private institutions, experts say. "Preparedness is really a community responsibility," says Nicole Lurie, assistant secretary for preparedness and response at HHS. That's especially important now that many patients are in skilled nursing facilities or at home, dependent on power to run electric wheelchairs and deliver oxygen therapy. A recent pilot project by the city of New Orleans in conjunction with HHS used federal data to identify such vulnerable citizens and sent people out knocking on their doors to be sure they had a plan in case of an emergency.
DeAtley, who is the administrator of the DC Emergency Healthcare Coalition, says these alliances can save money, too. His hospital was able to go in with others to buy $70,000 worth of personal protection equipment like biohazard suits that would have been more expensive if it hadn't been purchased in bulk. And they can facilitate coordination in the aftermath of a disaster. "If you take everyone to the nearest hospital, it becomes so flooded that you can't optimize care," says Lurie.
That highlights one of the gaps experts still see in preparation: the capacity of the system to absorb and care for a large number of people over a long period of time, as in a flu pandemic or after a crippling storm. New York-Presbyterian had prepared for a hurricane after Katrina; it installed watertight doors to protect infrastructure in flood-prone areas, for example. And so NYP hunkered down for Sandy in late October 2012 by discharging patients who could safely be let go, canceling elective surgeries and planning nearby housing for employees so they could be sure of getting to work.
But Sandy caused far greater floodingthan anticipated, knocking out even backup power systems and requiring New York City hospitals, nursing homes and other medical facilities to evacuate 6,300 patients; NYU Langone Medical Center, for instance, had to move out about 300 patients, including premature infants, many of them in the middle of the night. Some damaged hospitals remained closed for months.
NYP was ready for the nearly 360 patients it took in. But the long-term closures "put pressure on us that we hadn't appreciated," especially when the seasonal flu kicked in, says chief executive Steven Corwin. The hospital set up tents to create additional treatment areas. Now its emergency response plans are being modified to put more emphasis on long-duration disasters. For example, NYP is working to make sure that next time there will be an adequate source of gasoline – in such short supply after Sandy that lines at open gas stations were often hours long – to fuel ambulances and transport employees. The hospital also plans to purchase additional evacuation equipment and to beef up its ability to communicate with employees at their homes.
Sandy was "certainly an eye-opener" in terms of the value of investing in backup equipment, says Dan Hanfling, an emergency medicine physician and special advisor on disaster preparedness and response at the Inova Health System in Falls Church, Va. While it can be expensive to buy and protect generators that go unused for long stretches, having to close down for an extended period costs hospitals dearly in lost revenue as well as the community in access to care, as he and colleagues pointed out in a commentary published in the Journal of the American Medical Association last November.