‘This Is Like in War’ – Lessons Learned about Hospital Hurricane Preparedness

“Failing infrastructure, the increasing density of cities and the growing frequency of extreme weather events create public health risks on a massive scale. In Houston, improperly maintained Superfund sites ― that is, profoundly polluted hazardous-waste sites ― could not withstand the waters that rose as high as streetlights in some areas. Drainage systems failed. Poisonous chemicals and dangerous bacteria spread via floodwater through residential areas. In the wake of a flood, mold can bloom inside devastated structures, putting people at risk of allergies, asthma and other respiratory problems.
As with Houston, overdevelopment in Florida is making people more vulnerable to hurricanes and flooding, as precious swampland and marshland is encased in concrete and high-density residential zones are built in risky areas like barrier islands. Hurricane Irma, which made landfall in Florida on Sept. 10, knocked out power for between 60 and 80 percent of residents across the state, underlining the need for more diverse kinds of energy infrastructure.” (A)

“All hospital systems maintain emergency plans of action for a looming crisis such as Irma…
Hospitals have electrical generators in place if needed, are tied into their local government’s emergency operations response centers, and have preselected and specially trained administrators and medical staff at the ready, along with their relief teams. Non-critical surgeries and routine patient checkups are postponed, and clinics and physician practices closed…
Systems with multiple locations have specific plans for each “based on hazards,” such as proximity to the ocean or river, said Karen Ketchie, Baptist Health’s director of emergency management services. That’s how they were prepared to move patients when conditions at each site warranted it, she said…
“The hospital … was built to enable a defend-in-place strategy. This is due to the high acuity of our population of patients, and removing them from the building might be dangerous,” he said. (B)

“After an estimated 215 people died in hospitals and nursing homes in Louisiana following Hurricane Katrina in 2005, policy makers realized that the nation’s health care institutions were ill-prepared for disasters.
One of the rules they created after years of discussion looked especially prescient in light of the tragic deaths on Wednesday of eight nursing home residents in Florida’s post-hurricane heat. But the rule, regarding power supplies and temperature control, will not be enforced until November, and even then, some patient advocates are concerned that it does not go far enough…
The new federal rule will require that nursing homes have “alternate sources of energy to maintain temperatures to protect resident health and safety.” But the rule does not specifically require backup generators for air-conditioning systems — the nursing home in Florida, Rehabilitation Center at Hollywood Hills, did not have such a generator — and now some are questioning whether the rule should.” (C)

Escalating a legal and regulatory fight, Gov. Rick Scott’s administration issued an emergency suspension of the license of a Broward County nursing home Wednesday after the deaths of nine residents following Hurricane Irma.
The license suspension was another step after the state Agency for Health Care Administration last week placed a moratorium on admissions to The Rehabilitation Center at Hollywood Hills and suspended the facility from the Medicaid program. The nursing home late Tuesday filed a lawsuit challenging the admissions moratorium and the Medicaid cutoff.
Eight of the residents died Sept. 13, three days after Hurricane Irma shut down the nursing home’s air-conditioning system. The license suspension alleged that four of the residents had body temperatures of at least 107 degrees when they arrived at a nearby hospital or when they died.
“Respondent (the nursing home) failed to maintain safe conditions in its facility; failed to timely evacuate its facility once conditions were no longer safe for residents; and failed to timely contact ‘911’ during a medical emergency,” said the emergency suspension order, signed by AHCA Secretary Justin Senior. (D)

First, the nursing home, called the Rehabilitation Center at Hollywood Hills.
Yes, it experienced a partial loss of power after Irma. But the real problem appeared to be that the staff didn’t act quickly enough after the air conditioning failed and patients became overheated and dehydrated, according to police, emergency responders, and family members of patients.
By the time emergency responders got there, the facility’s second floor was “extremely hot,” some patients were already dead, and others were near death, Hollywood Police Chief Tom Sanchez told reporters.
Also, help was just a few steps away. Memorial Regional Hospital, which is right across the street, had power and a fully functioning emergency room when the deaths occurred.
When the hospital finally learned what was happening, dozens of workers rushed over to help, says Randy Katz, an Emergency Medicine specialist at Memorial. (E)

The first call from the Rehabilitation Center of Hollywood Hills to Florida Power & Light was placed about six hours after Hurricane Irma made landfall in Cudjoe Key on Sunday.
Irma had knocked out power to the center where 141 elderly and frail patients lived, and the following morning FPL said it would be there to restore electricity to the air conditioning units, according to a time line provided to the Miami Herald on Friday by officials of the nursing home who asked not to be identified.
The allegations in the time line — that the facility called both FPL and the governor’s cellphone for help that didn’t come, along with comments from the state and the governor’s office denying the nursing home’s version of events — added confusion Friday to a case that includes a criminal investigation into the deaths by Hollywood police.
According to the nursing home time line, FPL didn’t show up as promised on Monday, or on Tuesday, and by the time the utility arrived on Wednesday morning to repair a transformer that powered the nursing home’s air conditioners, all of the patients had been evacuated and eight elderly residents were dead. (F)

“The Texas Hospital Association this week estimated that as many as 75,000 hospital employees experienced losses and damage from Hurricane Harvey, both the storm and subsequent flooding. The association, which is based in Austin and represents more than 85 percent of the state’s acute-care hospitals and health care systems that combined employ some 365,000 health care professionals, announced Sept. 5 that it is contributing $1 million to a special assistance fund for the affected employees….
“Throughout the storm and the days following, we witnessed firsthand the dedication of our health care workforce,” said Ted Shaw, THA’s president and CEO. “Many of these individuals stayed committed to their work, knowing their families and property were at risk. While hospital administrative personnel, nurses, and other staff train for unspeakable disasters like Hurricane Harvey, their preparation and focus ensured the safety and continued operation of facilities even as the waters rose and the lights went out. Now, it’s time for us to take care of the caregivers.” (G)

“Patricia Ney was a nurse. The 56-year-old worked in the obstetrics department at Cape Coral Hospital for more than three years. In total, her career spanned more than three decades. Until last week…
The hospital system’s emergency preparedness plan in case of hurricanes is called “Code Brown.” During hurricanes, essential employees are grouped into two groups — A and B. Group A staffs the hospital during the storm and Group B takes over after to relieve the first staff workers.
Ney was part of Group A, but the day after Labor Day she went to Pennsylvania on a previously planned trip. At the time, Irma was forecasted to hit the east coast of Florida, but the cyclone surprised all by going west instead.
Under the previous guidelines for Code Brown situations, employees who did not go to work were placed under corrective actions and in some circumstances fired.
But because Irma was so remarkably unpredictable and affected large swaths of the state, Briggs said the guidelines will be tweaked allowing those employees to return to work. (H)

Local emergency management officials and state public health officials dodged a bullet with Hurricane Irma. They must do a better job of coordinating with local hospitals the care of hurricane evacuees who have been deemed “medically needy” because of serious health issues.
Emails obtained by this newspaper showed that as Hurricane Irma bore down on Chatham County, the three local hospitals initially flinched and backpedaled on their previous agreements to house 48 fragile members of the community, and that only Memorial University Medical Center eventually lived up to its commitments, but only after Chatham Emergency Management Agency Director Dennis Jones did some serious arm-twisting with top Memorial execs.
Candler accepted none of the evacuees it was assigned and St. Joseph’s, Candler’s sister hospital in the two-hospital system, accepted three “last minute” cases. (I)

“Furniture damaged by floodwater during Hurricane Irma that’s now sitting in front of people’s homes has started attracting people looking to salvage metal from it. But there is a hidden danger that could lead to infection if you aren’t careful.
On Jacksonville’s Northside, which saw a lot of flooding, two men were seen salvaging materials from soaked furniture…
“E.coli is the most common bacteria that can cause a variety of different problems,” Ashbaugh said. “Also, people with staph and strep — that can become a big problem with cellulitis, different abscesses and skin diseases.” (J)

“Nancy Reed, 77, died on Sept. 15 of flood-related necrotizing fasciitis, an infection that spreads quickly through muscle tissue and can cause organ failure…
According to the Centers for Disease Control and Prevention, necrotizing fasciitis is a serious bacterial skin infection that kills the body’s soft tissue, spreads quickly and can be fatal in a short time. Prompt diagnosis and treatment with antibiotics can prevent death.
The infection is not considered a reportable disease in Texas, meaning doctors or laboratories who diagnose it are not required to alert health authorities. But they are required to report many of the organisms that cause the disease — streptococcus, E. coli, vibrio vulnificus and certain types of drug-resistant staphylococcus.
Strep is the most common cause of flesh-eating bacteria. Vibrio is the most common in salt water. (K)

“The major general hospital for the Caribbean island of Dominica has already taken a major beating from Maria. It’s too early to tell just how much damage there will be to the Puerto Rican health system; but medical facilities on the island have historically been underfunded, putting even more strain on health care providers in the midst of an economic crisis in the region. And widespread power outages are expected for the foreseeable future, which will force patients to rely on backup generators and aid organizations.” (L)

“Health and safety are always concerns after such a disaster, but Puerto Rico must try to address those with the island largely devoid of electrical power and with a severely damaged communication system…
There are immediate needs of making sure hospitals can continue to run on generators, which require fuel that is in demand. It’s unknown how many people are trapped in homes that can’t get to a hospital or need some kind of health aid, such as a nebulizer, medication or assistance with getting around…
Jaime Pla, president of the Puerto Rico Hospital Association, told NBC News that hospitals have been able to operate normally for the past 48 hours because they have been on generator power.
“The issue we’re going to have is accessibility to diesel,” said Pla, adding that most generators operate on diesel tanks that last between three to five days…
All of this comes after Puerto Rico’s medical system already was strained as doctors have been leaving the island because of the economic crisis, as NBC News reported last month.” (M)

“The hospitals have been crippled by floods, damage and shortages of diesel. The governor said that 20 of the island’s hospitals are in working order. The rest are not operational, and health officials are now trying to determine whether it is because they lack generators, fuel or have suffered structural damage. All five of the hospitals in Arecibo, Puerto Rico’s largest city in terms of size, not population, are closed.
Making matters worse, 911 still does not work, officials said…
So far, seven regional hub hospitals are taking in patients. The island’s dialysis patients are also getting care. But none of it is easy. Hospitals should be required to have backup generators, diesel, a stockpile of medication and satellite phones, the doctor added. Even with those precautions, problems could arise. There is enough diesel on the island, but a shortage of gas tanker drivers — some cannot get to their jobs — and working gas stations. In Lares, the mayor, Roberto Pagan, said the municipal hospital almost had to close yesterday because it ran out of diesel fuel.
“We have been putting out fires,” Dr. Rodríguez-Mercado said. “The hospitals call you and say, ‘I have two hours of diesel left.’” (N)
“Coast Guard planes are flying in fuel, food and water from Miami and Jacksonville. The Navy hospital ship, U.S.N.S. Comfort, with 1,000 beds and 12 operating rooms, is also headed to the island. And the Department of Defense announced that U.S. Northern Command will have a commander on the ground in 24 hours.
“The issue in responding on an island is that you can’t drive trucks in like you can on mainland U.S.,” said Will Booher, a spokesman for FEMA…
At Centro Medico in San Juan, the main hospital on the island, power went out again Tuesday, forcing staff to switch to generators that have to be constantly refueled, said Jorge Matta González, the hospital’s executive director of medical services. (O)

“Aid is finally reaching the islands—fuel for generators, water, medical supplies, food—but disasters always breed disasters. And that might be what’s about to happen in Puerto Rico, too. “The first impact is people who were directly injured,” says Nahid Bhadelia, medical director of the special pathogens unit of the National Emerging Infectious Disease Laboratories at Boston University. “Then you have an entire group of people who are critically ill, facing health care systems that are overwhelmed.”
If things don’t get fixed quickly, the third wave comes. The islands are dealing with standing water, little clean water, and high heat. Those are perfect conditions for waterborne and mosquito-borne diseases—diarrheal diseases, and things like chikungunya, Zika, and dengue.” (P)

‘About 90 patients evacuated from Puerto Rico and the Virgin Islands are receiving kidney dialysis at Florida International University in Southwest Miami-Dade under a hurricane recovery response program coordinated by the state’s Department of Health.
Among the most urgent patients evacuated from Puerto Rico were the three infants with heart defects, who were born in August and September…
For transportation, Nicklaus Children’s turned to its LifeFlight program, an air ambulance service that flies jets packed with advanced life-support equipment for transferring critically ill newborns from the Caribbean, and Central and South America to Miami for medical care.” (Q)

“Evacuees from Puerto Rico and the U.S. Virgin Islands are being transported to mainland hospitals to receive care for critical medical conditions caused or impacted by Hurricane Maria.
In South Carolina, more than a dozen evacuees have arrived at the Columbia Metropolitan Airport by C-130 or private jet to be transported to various medical facilities around the state’s capitol…
In Puerto Rico, 59 out of 68 hospitals are open but not considered fully functional. Troy and her team from Fort Jackson are a part of the National Disaster Medical System, N.D.M.S, and Federal Coordination Center, F.C.C, which were activated in cities within the southern states of Louisiana, Mississippi, Georgia, and South Carolina in an effort to provide free medical assistance to those suffering from life threatening issues.” (R)

“Texas hospitals canceled surgeries, evacuated patients, and closed for days because of Hurricane Harvey. They sank millions of dollars into not caring for patients as a measure of precaution.
More than a month after Harvey made landfall, administrators at the roughly two dozen hospitals that evacuated in the eastern part of the state have now reopened their doors to patients. But some may feel the financial burdens of the storm for months to come — both caring for more patients who can’t afford treatment, while also seeing patients postpone the more lucrative elective surgeries that are many hospitals’ moneymakers.” (S)

“Hurricane Maria took almost everything from Rodriguez save for what he could fit into a backpack: the medical school he attended on the Caribbean island nation of Dominica and his family’s home in Puerto Rico. But he vows it won’t take his future — indeed, it has helped him find it.From his uncle’s house in Homestead, Florida, Rodriguez calls his experience surviving Maria “life-decisive.” In an interview by phone, he told CNN it has pushed him to pursue a new career path in his final semester at Ross University School of Medicine — emergency medicine.It was a decision born in the midst of a crisis.” (T)

“With Hurricane Irma menacing Florida, the leader of a state university campus decided on her course of action: Flee. As the storm approached earlier this month, Sophia Wisniewska dashed off an email to her boss. It included a description of the campus and indicated all was quiet at the University of South Florida at St. Petersburg.
It did not include any indication that Wisniewska was decamping for Atlanta…
Now, Wisniewska is out of her job as regional chancellor at USFSP, forced to negotiate her resignation. USF officials this week released a copy of the resignation agreement to The Washington Post, as well as a draft of a scathing termination letter from USF System President Judy Genshaft. (U)

(A) How Houston Can Become Stronger After Hurricane Harvey, by Anna Almendrala, http://www.huffingtonpost.com/entry/houston-hurricane-city-infrastructure_us_59c019f0e4b093cfe7761771
(B) Hurricane Irma: How Jacksonville-area hospitals responded to latest weather crisis, by Beth Reese Cravey, http://jacksonville.com/news/metro/2017-09-15/hurricane-irma-how-jacksonville-area-hospitals-responded-latest-weather-crisis
(C) Nursing Home Deaths in Florida Heighten Scrutiny of Disaster Planning, by NEIL REISNER and SHERI, https://www.nytimes.com/2017/09/14/us/nursing-home-deaths-irma.html?_r=0
(D) State suspends license of nursing home where 9 died after Hurricane Irma, by Jim Saunders, http://www.orlandosentinel.com/news/breaking-news/os-hurricane-irma-nursing-home-suspended-20170920-story.html
(E) When Irma Arrived, Most Florida Health Care Facilities Were Ready, by JON HAMILTON, http://www.npr.org/sections/health-shots/2017/09/19/551920301/when-irma-arrived-most-florida-health-care-facilities-were-ready
(F) Nursing home says calls for help went unanswered but state disputes claims, by DANIEL CHANG, http://www.miamiherald.com/news/weather/hurricane/article173630881.html
(G) Harvey Affected About 75,000 Hospital Employees in Texas, https://ohsonline.com/articles/2017/09/22/harvey-hospital-employees.aspx?admgarea=news
(H) Lee Health fires then rehires its essential employees who did not work during Irma, by MELISSA MONTOYA, http://www.news-press.com/story/news/local/2017/09/21/lee-health-fires-then-rehires-its-essential-employees-who-did-not-work-during-irma/687117001/
(I) Editorial: Come up with better plan for medically needy evacuees, http://savannahnow.com/opinion/editorial/2017-09-23/editorial-come-better-plan-medically-needy-evacuees
(J) Storm debris, floodwater-soaked furniture pose health risks, doctors warn, by Erik Avanier, https://www.news4jax.com/weather/hurricane-irma/storm-debris-floodwater-soaked-furniture-pose-health-risks-doctors-warn
(K) Kingwood woman confirmed as Harvey death from flesh-eating bacteria, by Cindy George and Todd Ackerman, http://www.chron.com/houston/article/Kingwood-woman-confirmed-as-Harvey-death-from-12230105.php
(L) Hurricane Maria Could Devastate Puerto Rico’s Underfunded Health System, by Sy Mukherjee, http://fortune.com/2017/09/20/hurricane-maria-puerto-rico-hospitals/
(M) Puerto Rico Attempts Recovery Amid Escalating Crisis and Dam Failure, by SUZANNE GAMBOA, https://www.nbcnews.com/news/latino/puerto-rico-precarious-situation-hurricane-recovery-begins-n803926
(N) The Crisis at Puerto Rico’s Hospitals, by OLGA KHAZAN, https://www.theatlantic.com/health/archive/2017/09/the-crisis-at-puerto-ricos-hospitals/541131/
(O) ‘This Is Like in War’: A Scramble to Care for Puerto Rico’s Sick and Injured, by LUIS FERRÉ-SADURNÍ, FRANCES ROBLES and LIZETTE ALVAREZ, https://www.nytimes.com/2017/09/26/us/puerto-rico-hurricane-healthcare-hospitals.html?mcubz=0
(P) https://www.nytimes.com/2017/09/28/opinion/puerto-rico-hurricane-maria.html?mcubz=0, by AM ROGERS, https://www.wired.com/story/puerto-rico-health/
(Q) Stranded in Puerto Rico after Hurricane Maria, infants flown to Miami for heart surgery, BY DANIEL CHANG, http://www.miamiherald.com/news/health-care/article176662251.html
(R) Hurricane Maria victims airlifted to mainland hospitals from US Virgin Islands and Puerto Rico, by Terace Garnier, http://www.foxnews.com/health/2017/10/04/hurricane-maria-victims-airlifted-to-mainland-hospitals-from-us-virgin-islands-and-puerto-rico.html
(S) Texas hospitals feeling the long-term financial strains of Harvey, byy MAX BLAU, https://www.statnews.com/2017/10/03/harvey-hurricane-texas-hospitals/
(T) Hurricane Maria took everything, but it gave med student a calling, by Paul P. Murphy, http://www.cnn.com/2017/10/06/us/hurricane-maria-survivors-story-future-trnd/index.html
(U) This university leader fled Florida during Hurricane Irma. Now she’s been ousted, by Sarah Larimer, https://www.washingtonpost.com/news/grade-point/wp/2017/09/20/this-university-leader-fled-florida-during-hurricane-irma-now-she-has-been-ousted/?utm_term=.88fe8b891f6d

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