Many U.S. Hospitals Called Unprepared For Big Disasters

SAN FRANCISCO – The deaths of 45 patients who were stranded at one of the many New Orleans hospitals that were crippled after Hurricane Katrina is forcing the nation's emergency-medicine experts to reexamine disaster planning.

Despite mandatory twice-a-year drills for an emergency in a worst-case scenario, many of the 5,000 hospitals across the land are ill-prepared to handle the kind of catastrophe that led to the tragedy at New Orleans' Memorial Hospital, experts say.

Some say varying state rules and loose overall regulation give many of the nation's big hospitals too much latitude in their planning, leaving them vulnerable in the event of a major disaster.

"Hospitals need to be prepared to deal with disasters by themselves for sustained periods of time, and most hospitals in this country are not capable of doing that," said Dr. Robert Suter, president of the American College of Emergency Physicians. For that matter, in his view, no hospitals are doing an "exemplary job" of getting ready for the unthinkable.

Hospitals in a crisis face daunting decisions such as when and where to evacuate patients, and their budgets force them to weigh preparing for a disaster that may never occur against the demands of everyday health-care needs.

Creating a kind of playbook to guide those decisions gets even more complicated thanks to laws restricting the transfer of patients to other facilities. And, like other businesses in their markets, hospitals tend to compete against each other for backup services and other scarce resources instead of cooperating, Suter said.

About 85% of American hospitals have been accredited by the Joint Commission on Accreditation of Healthcare Organizations, the industry's main standard-setter.

To get the commission's stamp of approval, hospitals are supposed to assess the hazard vulnerability risks in their area, make a disaster plan and run drills twice a year -- one inside the hospital and one coordinating with the larger community.

Most hospitals' city-wide drills focus on how to handle large volumes of patients affected by a disaster and rarely include themselves as part of the crisis, Suter said. "The scenario of you're affected by the disaster and have to evacuate to other hospitals, all of which every day you compete with, is not something that's usually done," he said.

Many hospitals that are part of a network of three or four other hospitals don't have the capacity within the system to evacuate the entire hospital, he said. "There needs to be more agreements between competitors in regions to evacuate and more overall surge capacity."

Until the federal government declares a state of emergency and sends National Guard troops, there is no known authority that can compel hospitals to work together, Suter said. "In general, the lack of any authority means that normally individual hospitals will conduct exercises that are focused on their own needs."

Early lessons

After Katrina left New Orleans flooded, one major problem was that several hospitals simultaneously recognized the need for total evacuation, putting them all in direct competition for life-saving resources such as specially equipped helicopters, said Dr. Robert Wise, vice president of the standards division of the joint accreditation commission.

Wise, who visited New Orleans after the storm, found many hospitals were still closed. However one of them, Ochsner Hospital, kept running when others went down, thanks in part to a well that provided water needed to run its air conditioning. According Wise, regulations that require having back-up generators don't specify that heating, ventilation and air systems be included on the power source, and he noted many other problems presented themselves.

"We were not aware of any communication systems that were ever well established between the command system and the hospitals," Wise said. "They were essentially isolated."

Disaster-planning standards generally anticipate cases in which a single hospital is disabled, but not cases of the surrounding community and support structure being devastated, he said. "You would be expected to know if your hospital lost its infrastructure, lost electricity and water, how it would be able to evacuate its facility to another facility. You would not be expected to know how it was going to be evacuated in the middle of a disaster like Katrina."

The joint commission has found a number of places where hospitals don't have a seat on their local emergency-operations centers. Wise said that although hospitals are expected to engage the community and try to integrate into the larger disaster plan, but accreditation isn't withheld from hospitals that aren't included in larger community plans.

"It is impractical and impossible for each hospital to figure out how to sustain itself for a prolonged period without the combined efforts of all the [community] assets working together," he said.

Suter, who also visited the New Orleans area briefly, said the airport that was run as a temporary medical center got down to one bottle of oxygen for some 7,000 patients who had yet to be examined there. "It wasn't any failure of plans in New Orleans, not a lack of knowing what the problems were," Suter said. "It was a lack of execution and not just at the time of the disaster but before."

Hospitals often get caught unprepared because of financial constraints, he said, noting spending on disaster planning typically amounts to less than 1% or 2% of a hospital's budget.

"It's a calculated risk being taken and if there isn't a disaster at your hospital, you win; and if there is, then the victims lose," Suter said.

Tightening planning standards

When it comes to testing, tight staffing levels and the need to keep hospitals safely operating during the drills can hamper the learning process and interfere with the purpose of doing dry-runs, Wise said.

"Typically, the hospitals have not drilled to the point of really stressing the system and seeing where their failure points are," he said. "Often drills have not been at the level of intensity to help an organization understand in advance where the vulnerabilities are. We are in the process of increasing the expectation for that standard."

Next year, the accreditation commission is likely to tighten rules for testing back-up generators. "It's a 30-minute test under a certain percentage of load," Wise said. "It certainly does not simulate what happens in a situation where there's a complete loss of all power or for a long period of time."

Hospitals should know they need to be self-sufficient for up to three days in an emergency, said Jim Bentley, a senior vice president at the American Hospital Association, a trade group representing about 85% of U.S. hospitals.

"Our advice to members is to plan to be 48 to 72 hours on your own," he said. "That requires more space and more storage and in a hospital system pushed to be as lean as can be that creates a tension, but my sense is hospitals have the capacity to do that."

After the terror attacks of Sept. 11, 2001, about $2 billion in federal bioterror money was distributed to states over four years to bolster their emergency responses to any disaster, Bentley said. States parceled out that money to various groups such as police, fire and public-health departments, but he estimates hospitals alone needed $11.5 billion to ramp up their capabilities sufficiently.

Even so, many urban areas were able to tap the funds to upgrade their disaster communications in hospitals and emergency transportation by installing 800-megahertz radio systems, he said. Both landline and cell phones failed to perform during New York City's hour of need, forcing many health-care facilities to rethink their emergency plans.

Health care on the fly

The decision to evacuate patients isn't made lightly because it carries substantial risks, said Hank Christen, director of emergency response operations for Unconventional Concepts Inc., a consulting firm that contracts with federal agencies on emergency preparedness and counterterrorism.

"These are frail patients that are power-dependent and not all are going to survive the trip," he said. "It's not an easy call. You will lose patients in the act of transporting."

But waiting can be fatal, too, he said. "If patients are in a storm surge zone, you've got to get them out of there."

Organizations typically need to have three levels of evacuation planning and contract with facilities 50 to 100 miles away as a back-up plan for a back-up plan, said Christen, who was emergency services director in Okaloosa County, Florida, from 1987 until 2000.

"We had nursing homes either contract private assets or use public school buses," he said. "You can't rely on the ambulance system."

Christen said he hasn't seen any of the New Orleans hospitals' plans, but that he's attended professional emergency management conferences since the mid-80s. "The New Orleans scenario was discussed at every one I ever went to... There's no way any professional in this business could justify saying they had not heard of this and were totally surprised."

Still, not every contingency can be covered if hospitals want to stay in business, said Dr. Joel Shalowitz, head of the health industry management program at Northwestern University's Kellogg School of Management.

"This is a huge, hopefully once in a lifetime event that in some ways you can't plan for," Shalowitz said. "You can't plan that this is going to happen at every hospital in the country because preparing for this would bankrupt the system."

AHA's Bentley agreed that planning can only prepare hospitals to a degree. "A disaster never plays out the way the disaster plan works."

The fact that patients needed to be evacuated outside state borders points to an overburdened health-care system, said Suter, who's also medical director at Spring Branch Medical Center in Houston and associate professor of emergency medicine and surgery at Parkland Memorial Hospital in Dallas.

To be sure, health-care workers did the best they could to set up temporary hospitals at places like Louisiana State University's basketball arena, he said. "For two days, a closed Kmart was one of the biggest hospitals in the state of Louisiana."

But undercapacity was a challenge too big to overcome, he said. "There are people who died waiting for the provider taking care of them to have a place to send them. If there had been capacity in the state of Louisiana in unaffected areas, they would have lived."

Said Suter: "Part of the body count from this disaster is due to the fact that hospitals have no surge capacity on a day-to-day basis in the health-care system."