CPR FOR HOSPITALS: CATASTROPHE PLANNING AND RECOVERY
Everybody understands Murphy's Law: “Anything that can go wrong, will go wrong, and at the worst possible moment.” But when it comes to catastrophes, Murphy was an optimist—during a catastrophe, Murphy's Law could be amended to say “Everything that can go wrong, will go wrong, at the worst possible moment, and all at the same time.”
Unfortunately, in our experience of hurricane recovery efforts during the tumultuous 2004 and 2005 hurricane seasons, we found this to be the case. Our company assisted hospitals recovering from damage associated with Hurricanes Charley, Frances, Jeanne, Ivan, and Katrina. These storms varied in intensity, size, location, etc., but all did serious damage to hospitals and surrounding areas. After the initial recovery efforts we began to work with our clients to strategically plan our responses and assist the hospitals in minimizing potential damages from future storms. All of these considerations have design and planning implications. Here's what we did and what we learned:
“Know thyself,” advised Socrates to the ancient Greeks. This definitely applies to catastrophe planning and recovery. Obviously, a hospital should maintain accurate records of its facilities and infrastructure. However, following a disaster, the need for accurate and comprehensive records of building systems becomes of paramount concern. With a looming event such as a hurricane, a checklist of items needed to assist with recovery would include the following:
Understanding the number and size of vulnerable building envelope openings, such as louvers, doors, and windows.
Understanding the location of any low-lying areas subject to flooding. Have sandbags and portable pumping capacity available to mitigate this risk.
Inventorying exterior and rooftop equipment susceptible to damage. Store information on this equipment, such as manufacturer, model number, electrical characteristics (voltage, horsepower, etc.), and any other pertinent information that would be necessary to quickly order replacement parts.
Photographing the facility, its equipment, etc. This not only assists with recovery efforts, but could be very useful in documenting pre-event facility conditions to prove to insurance adjusters that damage was caused by a hurricane or other disaster.
Locating and safely storing important hospital documentation, such as as-built drawings of the facility. This information provides valuable pre-event documentation and can also be used as a blueprint by contractors providing repairs.
Having the IT Department make copies of vital hospital records online. Many hospitals now use off-site storage for electronic information; all hospital records should be uploaded to these remote sites in advance of pending disasters in which an extended power outage is possible.
Protecting hard copies of hospital records, such as medical records, financial information, etc. Consider off-site storage for this. If this is not possible, temporarily relocate this information to non-exterior-proximate areas of the building (preferably in a room that is above the flood plain and not directly under the roof to avoid damage from a compromise in the building's envelope).
Understanding the hospital's electrical system (voltage and load) and the location of the incoming electrical service(s). Make sure you and the facility staff know what lights, receptacles, radiology equipment, mechanical equipment, etc., will remain available without utility power. Consider how you might connect a large portable generator to the hospital's normal power service to supplement the existing on-site emergency generator.
Understanding the hospital's incoming water service—pipe size, location, the facility's expected consumption rate, etc.
Preparing a contact list of individuals and companies that may be needed following a disaster. This list would include contractors, engineers, cleaning companies, various supply companies, insurance companies, etc. Contact these people beforehand and make sure they are willing and capable to assist you following a disaster. Consider the location of these companies—for example, following a hurricane in which your hospital has sustained damage, local contractors and other companies may be suffering similar damage and be unable to help. Think about supplementing local staff with outside groups who might be less affected by your event.
Ensuring that your reserve fuel is at capacity levels and that you have an agreement in place to get additional fuel to your facility in a timely manner.
Having enough food and water available for patients, staff, and family members of both patients and staff, along with any potential volunteers, repair contractors, etc. The state of Florida requires, for example, that new hospitals store a minimum of 3 gallons/patient/day and 1.5 gallons/staff/day.
After the event: The first 48 hours
Unfortunately, space does not permit a thorough discussion of the countless number of operations that need to occur at a hospital as it attempts to serve its community following a disaster. Rather, this article focuses on four major infrastructure issues that typically require immediate attention. Addressing these items early in the recovery process will help ease hospital personnel's efforts, making their jobs easier:
Repair damaged openings and restore facility infrastructure
Restore power, often via temporary means if necessary
Restore water, again with temporary means possibly necessary
Restore air conditioning
Obviously, the most important first step becomes repairing any building envelope damage. A facility anticipating an impending natural disaster would be wise to have a roofing contractor on standby to begin immediate repairs. Following the storm, this roofing contractor would have material readily available to begin these repairs. Similarly, a general contractor should be on alert to assist with damage to walls, windows, doors, louvers, and so forth.
The next important step is restoration of electrical power (assuming power has been lost during the event). In a disaster, utility power may not be available for an extended period of time. Keep in mind, national codes and standards only require certain equipment be provided for emergency power for a hospital. For example, air conditioning equipment is not a code-required emergency load. As a result, many facilities have no air conditioning on their emergency generator.
After some of the recent hurricanes, many hospitals have used temporary generators to “backfeed” their normal electrical systems while utility power remains unavailable. Hospitals choosing this method should have a temporary generator supplier contacted before the storm so that this equipment can be brought on-site quickly following the storm. Some hospitals have even gone so far as to station this generator (usually contained inside a tractor-trailer vehicle) held at a location near the facility but outside the immediate storm's path.
To safely connect a temporary generator to the hospital's electrical service equipment, hospital staff should ensure that they have qualified electrical staff on board or use the services of a qualified professional. Hospital maintenance staff must be prepared to service any portable equipment, such as a temporary generator, to ensure its extended operation. A large portable generator may require 60 to 100 gallons of diesel fuel hourly (depending on its size and building load); maintenance personnel must be prepared to maintain this fuel supply. Pre-arrange this service with a supplier prior to the event, because fuel becomes very difficult to find after an event.
Another life's blood for any hospital is water. Not only does water address diverse needs, from laboratory use to food preparation to flushing toilets, etc., most hospitals use centrifugal-type chillers to provide air conditioning; water pressure must be maintained to allow the cooling towers to reject heat through the chilled water system.
Hospitals should have an ongoing plan for storing potable water to assist with disaster preparedness. Bottled water remains a common alternative. However, some hospitals store collapsible containers that require only minimal storage but can be expanded and filled with water prior to a known disaster event, such as a hurricane. Portable desalination/reverse osmosis water generators are another option.
For nonpotable water, many hospitals have arranged for water to be brought on-site via trucks with large storage tanks. For example, some facilities pre-arrange that rental use of trailers that typically transport liquids (such as orange juice) to pick up water from outside sources and bring it to the facility. Post-Katrina, at Biloxi Regional Medical Center, Biloxi, Mississippi, the hospital contacted a fire department from outside of the hurricane's path to fill empty tanker trucks with nonpotable water for the facility. A manifold system (figure 1) was arranged to provide temporary connections and pumping from these tankers into the hospital's existing domestic water piping (figure 2).
Manifold system for water transported to a hospital site after Hurricane Katrina at Biloxi Regional Medical Center, Biloxi, Mississippi
A temporary tie-in to connect the temporary water supply to Biloxi Regional Medical Center's existing domestic water system
Restoration of some form of heating, ventilation, and air conditioning (HVAC) becomes an important next step. Besides providing a needed “creature comfort” to help ease staff and patient concerns, the HVAC system serves important functions such as removing moisture from the building to prevent the growth of mold and mildew (figure 3), helping minimize airborne diseases and allowing necessary hospital equipment, such as electronic medical records, radiology equipment, etc., to properly operate by removing heat generated during normal operation. Temporary HVAC systems (figure 4) are available similar to portable generators. Also as with emergency power, temporary HVAC systems should be arranged ahead of a disaster if at all possible and will require fuel and maintenance during the aftermath.
Mold damage on a hospital wall caused by water damage during a disaster
A temporary HVAC system installed following a hurricane
In addition to the above concerns, many other issues must be considered and addressed during disaster recovery at a hospital.
Set-up a chain of command before the event. Know who will make the necessary decisions. Divide the work into manageable pieces and assign tasks accordingly.
Set-up a command center. For example, daily meetings held at pre-arranged times will help ensure that all staff and any remediation contractors are properly informed of issues and decisions.
Be prepared with additional communication procedures. With telephone service often unavailable after a disaster, portable radios may serve an important role to allow recovery staff to communicate with each other. Also, if outside communication is necessary, a satellite phone may be considered.
Contact vendors for necessary supplies beforehand. These vendors may be providing anything from generators, diesel fuel, and ice to medical supplies, food, and nonpotable water. Negotiate pre-arranged rates, delivery schedules, etc., as necessary.
Help the staff. Often, hospital staff will not ome to the hospital until their own families are taken care of. The hospital may have to provide additional provisions, food, water, or sleeping accommodations to staff's family members.
Help the community recover. For example, during one of our recovery efforts a hospital provided a temporary generator to help get the city's local water plant back on-line.
Be prepared to support surge hospitals that develop in the area. These facilities can help alleviate overcrowding in a hospital by handling many of the less severe healthcare needs and minor injuries. For more information on surge hospitals, please visit http://www.jointcommission.org/PublicPolicy/surge_hospitals.htm.
Hospitals always play an important role in their communities. This importance of this role magnifies following a disaster during which the community suffers extensive damage. Hospitals must take this responsibility seriously.
For example, this occurred following Hurricane Katrina in 2005. Our company was one of many that assisted Biloxi Regional Medical Center in Biloxi, Mississippi, in recovery efforts following this devastating storm. This hospital, located merely three blocks from the Gulf of Mexico, served a community devastated by this hurricane. For days following the storm, this hospital remained the only building in town with power, water, air conditioning, and many other basic necessities. The hospital served so many community members post-Katrina that a temporary emergency department had to be set up in tents outside the building to assist with minor issues and help prevent overcrowding within the building.
All this was available because preparations had been made, and swiftly implemented after the storm, by the hospital and its owner, Health Management Associates (HMA). HMA brought in nurses, doctors, and other staff members from many of its other hospitals to help. The city used the hospital for functions such as a makeshift post office and city hall since these community buildings were damaged and without power. The hospital's main lobby even served as a supply and distribution center for donated items such as clothes, toys, and other personal items for people who had lost their homes and/or possessions.
By planning for and implementing your facility disaster plan, you too can bring your facility (and community) back to life after an event—administering, in effect, CPR on your hospital. HD