In May 2011, as a massive tornado barreled toward Joplin, Mo., St. John's Regional Medical Center braced for impact. Staffers closed curtains, moved objects away from windows and transported patients to chairs in the hallways. After the tornado dealt a direct blow, destroying generators, shutting down communications, peeling off the roof, blowing out windows and turning IV poles into projectiles, they shifted into disaster mode, moving out patients who could walk and using evacuation sleds and even doors ripped from their hinges to take those who couldn't walk down as many as nine floors. Critical patients were quickly sent to another hospital; the emergency department set up operations on a safe area of the street. Afterward, people told me they "knew exactly what [they] should be doing," says Dennis Manley, then director of quality and risk management for the hospital and now vice president of quality for Mercy Hospital Joplin. "All that drilling and education really does pay off," he says.
And there has been a lot of it. Hospitals have significantly boosted their readiness for disaster since Sept. 11, 2001, and the anthrax attacks that began just a week later. Those two events served as a vivid reminder that the country's overtaxed emergency departments needed to somehow get ready to cope at a moment's notice with "an influx of patients with any number and any type of injury," says Craig DeAtley, director of the Institute for Public Health Emergency Readiness at the MedStar Washington Hospital Center in Washington, D.C. Hurricane Katrina and the fear of a pandemic sparked by SARS and bird flu only added to the sense of urgency. The Institute of Medicine and the Centers for Disease Control and Prevention have increasingly urged hospitals to prioritize preparedness. And emergency management standards from the Joint Commission, which accredits hospitals, now require them to perform two practice exercises per year.
Hospital executives who have watched the hits keep coming – Superstorm Sandy, mass shootings, the Boston Marathon bombings – are convinced "that they need to invest in this," says Eric Toner, senior associate at the University of Pittsburgh Medical Center's Center for Health Security, located in Baltimore, Md. "My own hospital has conducted more than 150 different training exercises in the last five years alone," says Paul Biddinger, medical director for emergency preparedness at Massachusetts General Hospital. Most are short training sessions to teach staff how to wear protective equipment or to use evacuation sleds. But a few are full-fledged simulations using actors and mannequins to play the role of patients.
That kind of exercise, which can cost $20,000 and include most hospital departments, served Mass General well in the aftermath of the Boston Marathon bombings, Biddinger says. The hospital, which treated 39 victims all told, took in 18 seriously injured people between nine minutes and two hours after the explosions, at a time when the emergency department was already dealing with twice as many patients as there were beds. Thanks to its readiness plan, an automatic call system immediately summoned transport staff to the ED so beds could be freed up within five to 10 minutes. The plan also brought needed specialists, such as trauma surgeons, to the ED, implemented a system of 15- to 30-second triage and rapidly made X-ray and CT machines available.
In the first couple of years after 9/11, readiness efforts focused mostly on purchasing equipment and shoring up communications capabilities. St. John's in Joplin, for example, bought its evacuation sleds; St. Elizabeth Healthcare, a system of hospitals serving greater Cincinnati and northern Kentucky, bought 120 15-channel radios so that area hospitals could easily communicate with each other.
Since then, the preparedness movement has also influenced renovation and new construction. New York-Presbyterian Hospital expanded its emergency unit with the anthrax scare in mind, making sure every room had isolation capabilities. When Rush University Medical Center in Chicago planned its new building, which opened in January 2012, the emergency department was designed to become part of the first-line response to a bioterrorism event or a pandemic. The ED rooms, usually singles, are equipped to accommodate two patients; the adjacent hospital lobby can also be used to house patients if necessary. That capability is baked into the architecture, with oxygen lines tucked into the lobby's support columns.
The emergency department itself is divided into three "pods" that can quickly be isolated from one another using negative airflow via the HVAC system, says Dino Rumoro, Rush's chairman of emergency medicine. Outside the ambulance bay, fire hydrants can be repurposed to hose down patients and begin the decontamination process.
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.
Tia Powell, director of the Montefiore-Einstein Center for Bioethics in New York and also an author of the JAMA commentary, notes that Sandy called attention, too, to the dilemma of evacuation – when to stay, when to go and how to decide. There's no national policy or established wisdom, she says.
For example, what to do about obese patients? "Even big, strong men will have difficulty moving a 500-pound person down 10 flights of stairs, and the majority of health care workers are women," Powell says. Some vulnerable patients might be better off sheltering in place, their rooms powered perhaps by a dedicated generator. "Evacuation is risky for patients, really complicated and hideously expensive," she notes.
Expense is a big obstacle to fillingthe gaps in emergency preparedness that remain. Funds dedicated to the government's Hospital Preparedness Program, which supports readiness efforts, have declined from an annual peak of about $500 million in fiscal 2003 and 2004 as the economy slowed and the issue faded from the top of consciousness; grants in fiscal 2013 totaled $332 million. And "so many hospitals are on the financial brink all the time," says Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University. "Preparedness efforts are low-hanging fruit when budget cuts are demanded."
The state and local public health situation is even worse, says Hanfling. An annual preparedness report from the Trust for America's Health released in December found that 35 states and Washington, D.C., achieved six or fewer of 10 key public health preparedness indicators such as having enough lab capacity to work 12-hour days, five days a week, for six to eight weeks, as might be required by a pandemic flu. "By and large, there's not a lot of terribly expensive stuff we need to buy," says Lurie. "But there's an ongoing need for training and exercises and knitting together the parts of the health care community."
Back in Joplin, construction is proceeding on a new and more heavily fortified hospital. And if another disaster should befall the community, Manley says, staffers will be even more prepared. The readiness plan has been revised to reflect the experience of those who worked through the tornado. Next time, patients moved into the hallway will have their shoes with them, in case the need again arises to maneuver through rubble and glass on the way to safety.