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Emergency Planning: Tornadoes and hurricanes

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March 30, 2017

It’s storm season. Now’s the time to get your facility ready to face the power of Mother Nature

Editor’s note: This is the last in a series of stories that will address common planning concerns when it comes to certain types of emergencies that can strike a hospital facility.

It’s spring time in the U.S., and with the return of warmer weather in most places, the mind turns to pleasant sunny days, lighter jackets, and at worst, spring rain showers from a weather perspective.

But from a meteorological standpoint, Mother Nature is just getting ramped up. In the U.S., tornadoes become more frequent in many parts of the Midwest as cold air in the northern half of the country meets warmer, more humid air in the southern half, creating the perfect soup for thunderstorms that can spawn brutally destructive tornadoes.

In parts of the country such as Florida, the Gulf Coast, and the Atlantic seaboard where tornadoes aren’t so prevalent, preparations begin for hurricane season, which begins in June and runs through November.

Both of these types of storms bring with them their own distinct dangers of wind and water, and while one type is usually small, quick, and violent while the other is large, and can span days over one spot, hospitals must be ready to deal with them both and to stay open to help both existing patients and incoming victims.

One would think after many years of having open hospitals in the U.S., that preparation for these storms would be second nature—and a direct strike is something that is almost statistically unfathomable. But one needs only to look at New Orleans in 2005, and Joplin, Missouri in 2011, to know how unprepared hospitals can be.

Hurricane Katrina hit the New Orleans area on August 29, 2005 as a Category 3 storm, which may not have been a big problem for the city’s medical facilities in normal circumstances, but when 53 of the city’s protective system of levees failed, almost 80% of New Orleans was left under water, sending citizens scrambling to the roofs of their houses to escape the ?oodwaters. Several hospitals were left stranded, with no evacuation plans, a lack of doctors (or the inability to get staff to and from work), and failed utilities that ultimately led to many deaths of patients whose life support systems failed. The storm’s aftermath led to many emergency preparation overhauls, and changed the way healthcare organizations plan and drill for disasters.

“Hurricane Katrina was an indescribable event that forced the hospital and the community to deal with issues that were not planned for,” recalls Ken McDowell, CHSP, CHEP, safety officer for Memorial Hospital at Gulfport in Gulfport, Mississippi, an area that was especially hit hard by the hurricane.

Direct hit from a tornado

On the afternoon of May 22, 2011, an EF-5 tornado with winds approaching 300 miles per hour slammed into the city of Joplin, Missouri and roared head on into St. John’s Hospital. In the aftermath of the tornado, 161 people died, including six at the hospital itself. The roof of the building was blown off, leaving those inside exposed to the elements. Cars in the parking lot were thrown into the hospital’s front foyer waiting room, and shards of glass sprayed patients and staff as just about every exterior window shattered. Communication was completely shut down, and an electrical generator and HVAC system on top of the hospital was tossed off and rendered useless.

Four years later, the city opened the brand new $450 million, 900,000 square-foot “tornado-proof” facility designed to withstand another direct hit. Utilities are hidden in a reinforced concrete utility bunker buried underground. Exterior walls are made with reinforced masonry and precast concrete panels designed to bow in and out to withstand pressure changes in a tornado, and the roof is built in layers—a concrete roof covered with a waterproof membrane designed to keep the roof from tearing off and exposing those inside to the elements. Special windows were made to withstand winds up to 250 miles per hour in the hospital’s most critical areas.

Clearly, man is no match for Mother Nature’s fury, but we’ve shown the ability to rebuild and learn some pretty important lessons out of experience. So how can you get ready for this year’s onslaught of wicked weather? The preparations for both types of storms are quite similar.

Our safety experts, along with those who literally weathered the two storms in Joplin and New Orleans helped us come up with some tips and advice to get you started in your preparations.

Assess your vulnerability. It’s been said many times, many ways. The only way you can get a clear picture of the hazards that could potentially strike your hospital (and more importantly, whether or not you’re ready to deal with them) is to do a hazard vulnerability assessment. If you haven’t done one yet, you’re already out of compliance with CMS and The Joint Commission (it’s a requirement). This is the document that measures the disasters that are likely to hit your community. (Is there a freight train line that carries hazardous chemicals that run through town? Is your hospital in the flood zone for a system of levees? Are you located in Tornado Alley?)

From here, you can tailor your response possibilities, and your drills that will help practice those responses. This is important, because it will help you determine where your weaknesses are. Is your facility prone to flooding? This might be good to know if your area is prone to hurricanes, because now is the time to mitigate that problem with a system of dikes, or to stock up on sandbags, or to practice your evacuation procedures. New York City hospitals learned this the hard way when Hurricane Sandy unexpectedly flooded the basements of older buildings, forcing the evacuations of many patients to other facilities.

Protect your utility infrastructure. This is your lifeblood. Without power, lights, heating, and other important utilities, you will literally be in the dark. If there’s one thing that hospitals that have weathered huge storms have learned, it’s that wind and floodwaters will find the weaknesses in your building’s infrastructure and creep into, or blow away, your utilities. After generators and utility connections were blown either out of or off the old Joplin hospital, architects placed all of the hospital’s generators, boilers, chillers, gas, and oxygen in the underground bunker, and twin electrical feeds will ensure a redundancy should one stop working.

“We do not know of another facility that has been built with tornado and wind protection as this new facility,” says John Farnen, executive director for strategic projects for Mercy Health Systems, St. Louis, Missouri, who helped design the new Mercy Joplin Hospital.

In what has been called an example of upside-down construction, many hospitals are being built or retrofitted with the main primary electrical services located in the rooftop and powered by a fuel pump that is secured in a flood-proof vault with a 150,000-gallon tank and reserve fuel stored on-site. Many emergency fuel tanks are stored in hospital basements or bottom floors. During Hurricane Sandy in New York City, many generators were worthless because floodwaters either contaminated emergency fuel stores, or destroyed the tanks. As a result, some hospitals, such as the newly built Spaulding Rehabilitation Hospital in Boston, are being built with ballasted fuel tanks that can float in floodwaters.

“The weather events of the prior decade drove our decisions, and time has proven us correct,” says Spaulding Director of Communications Timothy Sullivan.

Some facilities are being built so that even if the first floor was completely flooded, critical care could still take place as usual in upper floors. At Spaulding, even the hospital’s parking garage is designed 19 feet above current flood levels, and the entranceway is designed with a special uphill “lip” that will cause water to pool, rather than rush down into the underground parking garage.

Foster mutual-aid relationships. Hospitals need to learn to work together to help out in an emergency. Before Hurricane Katrina, hospitals in New Orleans didn’t have “memorandums of understanding” with other hospitals that let other hospitals accept their patients should the need arise. Now, it’s considered best practice in your emergency plans to have deals with other hospitals. Hospitals in the same community now routinely train to not only sustain themselves in an emergency, but with other facilities to be ready to help out with supplies or patient care if needed. A similar agreement went into effect in Joplin after the twister, when Freeman Hospital, six blocks away and untouched, took in more than 100 of the most critical of patients who had been evacuated from St. John’s, but also about 1,700 patients that had walked into the emergency room off the streets. Emergency surgeons performed 22 lifesaving operations in the first hour after the twister struck.

“We had to resort to very primitive measures that day,” says Paula F. Baker, president and CEO of Freeman Health System in Joplin. “We had doctors and nurses who literally crawled out of their own homes that had been destroyed to come here and help. You couldn’t get through the streets here, so they walked and did whatever they could to get here.”

You need to drill, constantly. Practice makes perfect. Unfortunately, hospitals don’t practice enough. When a disaster strikes, hospital staff response needs to be a well-oiled machine. Take, for instance, the tornado in Joplin. When the tornado hit, staff members only had about five to 10 minutes to prepare. Only minutes remained to move patients to rooms and hallways in the center of the hospital away from windows and outside walls. In the aftermath, patients had to be evacuated down stairwells that had collapsed, ceilings that were falling down, and lights that weren’t working. Your hospital may have a system in place for doing something similar, but if you haven’t practiced getting people out of the building, your staff won’t know how to handle it when they are truly under the gun. At least once a year, and preferably much more often, hold a real-life drill that simulates deteriorating conditions and forces your staff to make decisions based on changing variables.

Invest in updated communication technology. You can have the best communication equipment money can buy, but if the power goes out, what then? It’s a rule of emergency management that if you can't communicate with the outside world, you are on your own, and that's exactly what happened to many hospitals after Katrina struck. When the power went out staff members tried to use cell phones, but downed towers from the wind and overcrowded circuits rendered cell phones useless. There were a few satellite phones available, but to use the phones, staff had to go to the roof of the hospital to search for a signal. Today, cell networks are much more reliable and cell phones are much more dependable. Still, cell towers won’t withstand a 300-mile-per-hour wind, and when your staff is trying to coordinate a mass evacuation down several flights of stairs after a tornado, they aren’t likely to pick up their cell phones to communicate. You may have to rely on shouted commands or codes, handwritten notes, or a system of walkie-talkies. Have those contingencies ready.

“We have installed a first responder radio system and a ham operators system in the new facility for communication with other emergency agencies in case we should ever lose everything again,” Farnen says. “We have more redundancies for utilities including UPS (uninterruptible power supply) backup on all life support equipment.”

Yes, regulators now require your hospital to test communications systems often, and have multiple backup systems available in the event of a crisis. But the best-tested systems still can fail. After the tornado in Joplin, patients were being transferred to Freeman with no patient records, since all communications by phone or computers were down. Security cameras didn’t work, and the only way to get a cell phone signal in some cases was to go to the roof of the hospital. The only way of knowing why the patient was being transferred, or what their medical history consisted of was by reading handwritten notes attached to the patient.

“Nothing could have prepared us for that,” says Baker. “We were working with every disadvantage against us.”

Have an evacuation plan, and know when to leave. One of the hardest decisions staff members of a hospital can make is the decision to evacuate. It’s an incredibly difficult undertaking that takes a massive mobilization of resources, time, and a ballet of making sure life-support systems are available to help keep critically ill patients alive. It’s not to be taken lightly. At the same time, it’s possible to wait too long to the point where it’s too late—and that’s a problem that struck facilities in New Orleans. Hospitals had always trained to stay open, and by the time the last option became the only option, the floodwaters had already risen too deep. Some will fault the government, which waited much too long to issue an effective evacuation order for the city, but it’s those timely decisions that make the difference between being able to get ambulances and buses in to help evacuate critical patients or to hole up at the hospitals waiting until helicopters were available to assist. At the same time, you are trying to make sure your staff can safely make it into work to help keep your facility operational. (It’s also a good idea to make sure your hospital has a plan to house staff members in case they need to stay for a prolonged period of time. If you know a bad storm is on the way, you may want to consider converting a conference room, for instance, into a hotel with cots where they can stay for a few days in case conditions are bad for travel.)

It’s a good idea to write your emergency plans with the forethought that at some point, someone may have to decide to evacuate. The idea is to know ahead of time who will stay and who will go, and at what threshold it is time to make that decision. If weather conditions are deteriorating rapidly, or transportation arrangements can’t be guaranteed, or resupply lines might be compromised, those decisions need to be made earlier so they never come as a surprise. Hospitals in the New York City area had ambulance companies on standby long before Hurricane Sandy ever hit, just in case they were needed.




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