Hurricane Katrina in New Orleans. An F5 tornado in Joplin, Mo. Blizzard Nemo in the Northeast. The earthquake and resulting tsunami in Japan. Nature has unleashed some devastating forces in recent years and these disasters have healthcare providers scrambling to re-visit their disaster plans. As the unscathed focus on preparation, the experienced share lessons learned.
Before the storm
In the middle of the Atlantic Ocean, nine days before Halloween 2012, Hurricane Sandy began to swirl toward the U.S. By Oct. 25, the storm had danced across the Caribbean, already responsible for dozens of deaths in Haiti, the Dominican Republic, Cuba and more.
Sandy was projected to hit the U.S. somewhere in the Northeast, sending healthcare providers in the storm’s path into preparation mode. For Tobias Gilk, MArch, senior vice president at RAD-Planning in Kansas City, Mo., however, disaster planning happens well before storm clouds appear on the horizon.
“The more thought that can be paid in advance of a capital project—whether buying a new piece of equipment or building a new wing or renovating a suite—the better prepared you’ll be to respond to emergencies and mitigate the damage that comes from emergencies,” says Gilk.
Standing behind the notion that an ounce of prevention is worth a pound of cure, Gilk says providers can use facility assessments to detect weaknesses before a problem strikes. Even if there are issues identified that can’t be immediately addressed, considering possible scenarios can help in the development of contingency plans. For example, a rural hospital with limited access to power should identify its critical needs and design a backup generator strategy to maintain those services in the event that additional power supplies may not be accessible during a major storm. Equipment that isn’t an essential need should be removed from automatically receiving emergency power.
Radiology departments should have a criticality list in terms of imaging resources, says Gilk. Plain film radiography may be considered more essential than ultrasound or a department may choose to maintain CT service over MRI. If only one modality can be brought online, Gilk says providers should identify which one it should be and which can wait a few days.
Natural disaster profiles available through the Federal Emergency Management Agency (FEMA) and state-level FEMA offices can help facilities with these priorities. The upside of contingency planning is that the first plan will have cascading benefits and responses translate over various scenarios, says Gilk. A blizzard or a hurricane could knock out power, but some aspects of the response will be similar for either event.
Plans also may help with unforeseen events. Gilk described a situation at one hospital that was built on high ground nowhere near a body of water. A natural flood would have been nearly impossible, but a pipefitter who broke a water pipe servicing a wing of the hospital managed to flood the ground level of the facility, demonstrating why all facilities should have a flood plan to protect vital equipment.
Another benefit of disaster preparation is its value in non-disaster scenarios. A trailer dock designed to deliver a CT unit in the event that one is damaged during a storm also could provide easy access during a scheduled servicing event when a department may need to use trailer-based service.
“This doesn’t have to be money sunk into the event we hope will never happen,” says Gilk.
Once in the path of a major storm, the next phase of disaster planning begins. At NYU Langone Medical Center in New York City, the radiology department asks its vendors to assess equipment as standard practice when there is potential for normal power to be lost, says Donal Teahan, director of radiology practice development. The department made sure that MR scanners were full of helium, so they would stay cool if recovery took more than a couple of days. The facility looked at chill water and backup parts in the event of a damaging power surge.
“You shut down all systems prior to the storm with the exception of MRI coldhead compressors,” says Teahan. “You shut down all power breakers just to make sure you don’t get a power surge, because a power surge is usually the biggest problem.”
Beyond these steps, there aren’t many technical issues that need immediate preparation before a hurricane, he says. “There’s little you can do until after the storm, because you don’t know what you’re going to be responding to.”
+ Disaster planning is not a waste of time. Providers may hope they never have to use it, but a comprehensive disaster and business continuity strategy is essential.
+ Don't underestimate human capital. Technology is important, but success is determined by how well staff can communicate and work together.
+ Expect the unexpected. Manmade disasters can be just as devastating as natural ones—and often less predictable.
+ Use downtime. If downtime does occur, it can be used to restructure, tackle back-burner projects and hit the ground running once operations are back online.
On the personnel side, establishing a line of contact with staff is key. At Beth Israel Medical Center in New York City, names and phone numbers of staff are accessed and personnel were alerted prior to the storm, says Marc Katz, corporate director of radiology. Once it was announced that mass transit service would be shut down, essential personnel were told to report to the hospital where quarters were arranged for sleeping.
Meanwhile, even providers outside of the direct hurricane path went through their own preparations, including the staff at Nathan Littauer Hospital in Gloversville, N.Y., nearly 200 miles upstate from New York City. The safety officer sent out twice-daily weather alerts and backup generators were re-checked. Staff contact was another focus. In a rural area, it can be especially challenging for people to get to the facility, says Michael McBiles, MD, chief of radiology. While the hospital was far from the hurricane storm surge, area roads could flood. In other cases, winter blizzards may force staff to stay at a hospital.
With staff communication accounted for, communication with patients is the next priority. NYU Langone set up toll-free numbers where calls could be forwarded if a normal hospital line was not connected. Patients could call the same number and get information even if normal phone service was cut.
With all reasonable preparations in place, all that was left to do was wait.
Hurricane Sandy made landfall on the New Jersey shore the evening of Oct. 29, 2012. Buildings all along the Jersey Shore were leveled and the boardwalk was lifted off its supports. In New York City, the storm devastated outlying areas and sent a record 14-foot storm surge into the harbor. The massive amounts of water pushing against the city flooded subway tunnels and the East River spilled over onto 1st Avenue.
Power was cut across the city. In some areas, the electric company purposely cut power ahead of the surge to limit damage. Other areas lost electricity after an explosion that destroyed a transformer. Around 9 p.m., normal power at Beth Israel went out and emergency power kicked in. The imaging equipment, including PACS and RIS, operated on emergency power.
The radiology facilities within Tisch Hospital at NYU Langone were not as fortunate. The East River crested more than 14 feet above normal, sending water into the basement and damaging equipment below ground level, explains Michael P. Recht, MD, chairman of the radiology department at NYU Langone Medical Center. Four MRI scanners, some CT systems and x-ray equipment were destroyed, and the entire main campus lost power.
With some hospitals unable to function, patients were redirected to other facilities. Beth Israel took on patients from NYU Langone and elsewhere, and most medical records were transferred on CD and hard copy. Beth Israel’s data were secured with offsite data storage in New Jersey. “From that perspective, there was little impact to us,” says Katz.
In terms of preserving and backing up images, standalone imaging centers likely have technology in place through their vendors, says Gilk. “In some cases, the smaller guys might have it a little bit better in that they should be set up with an external, automated back-up system, typically through a third-party provider.” Large healthcare systems are in the same game as Amazon or other commercial data hosts, he says. They typically provide their own servers and in-house data management, and must ensure an appropriate level of redundancy and backup.
Radiologists are fortunate, says McBiles, because they can leverage electronic communications to interpret exams remotely. “If the internet is up, you can do 90 percent of the work in radiology.”
Digital communication between hospitals allows for easier transfer of patient data, but requires pre-planning. “It has to be done beforehand,” says McBiles. “If another hurricane came through and you didn’t have those agreements, you couldn’t set them up during the storm, because it does take some expertise to negotiate the firewalls and internet issues.”
Despite the best planning efforts, some systems could be lost in a disaster scenario. The solution is often creative problem-solving. For example, PACS can be installed in a cart-mounted, mobile server if the main server room is compromised. Open source CDs of programs should be handy as backups to reinstall needed software. Smaller sites that don’t have a robust IT infrastructure can revert to old-fashioned processes—printed schedules and patient and staff contact information on paper.
In the immediate aftermath of the storm, Recht says the NYU Langone’s radiology department focused on redirecting patients who required outpatient imaging services. The main hospital was not operational–so there was no need for inpatient scans–but some affiliated outpatient imaging centers were open. The scheduling team, many working from home, rescheduled patients who had planned exams far in advance of the hurricane.
Since reading rooms were not operational, a call was made to the entire department for volunteers to relocate workstations. Though many staff were dealing with their own personal and logistical challenges following the storm, Recht says that more than 60 people, from front desk staff to technologists to residents and fellows, showed up to carry computers up and down stairs for transport to a new building several blocks away.
The main campus of NYU Langone has been in the process of major renovations and construction to make way the new Kimmel Pavilion, slated to open in 2017. Several radiology offices and reading rooms were scheduled to be relocated early in 2013. The storm forced an impromptu head start on that move.
“We had no idea how many people were going to show up to help us move and we had a huge turnout,” says Recht. Both he and Teahan spoke with high praise for the staff, many of whom were without electricity at home, and how they came together during the recovery. At least one staff member bicycled from Brooklyn three days in a row to come to work and help with recovery.
“People respond because they want to be part of a group and maybe that’s the best prep for any kind of a storm—to have the right people who are willing to go above and beyond as a group to make things happen,” says Teahan.
A new direction
Disaster recovery isn’t just about picking up and reassembling the pieces after a shutdown. In some cases, it can provide an opportunity to make lasting changes that improve a department’s operations.
At NYU Langone, Recht says the storm forced the department to rethink workflow to improve efficiency. “Equipment was the key part of what we needed and we thought that was the limiting factor. What we learned is that by utilizing more people, we were able to perform the same or more examinations [on two CTs that used to be done on three CTs].” With a higher staff-to-scanner ratio, there are more people to help with patient flow and technologists reported having a better experience with the additional support.
The experience taught the department to be more people intensive and not so focused on capital equipment, says Recht. Going forward, the department will continue to operate with one less CT scanner than before the storm.
In the reading room, a shift was made to a more communal atmosphere with fewer silos for the various subspecialties. In the past, there were separate reading rooms for chest radiologists, neuroradiologists, pediatric radiologists and more, and in the aftermath of the storm, out of necessity all radiologists worked in one of two large reading rooms. Subspecialists realized they liked being together in the same working environment and that it fostered a new sense of teamwork and camaraderie, says Recht. The department hopes to continue this model.
One challenge of the communal room will be making sure all radiologists can work together using speech recognition. The new configuration will include some specialized reading rooms, but it will keep more common reading rooms because of the benefits.
Aside from restructuring certain areas, the downtime after the storm provided an opportunity for subspecialists to expand their armamentarium. Each section was directed to think about a project they didn’t have time for in the past and to take action. “We really said ‘we all have to use this time wisely to make us a stronger and better department when we came back,’” says Recht.
Some thoracic imagers wanted to learn more about cardiac imaging in advance of the department combining the separate cardiac and thoracic imaging sections into a single cardiothoracic imaging section. They used the time to read with cardiac imagers or take a course on the subspecialty.
Others in the department were given more academic time to work on grants, and some developed their expertise in PET/MR imaging, because NYU Langone had acquired one of the hybrid modality scanners earlier in the year.
Every disaster is different and brings its own set of hard-learned lessons. Following Katrina, hospital building codes were revised after high winds and flooding hampered medical centers in and around the city of New Orleans, says Gilk. New York City Mayor Michael Bloomberg has stated that the city will craft future hurricane and flood protection infrastructure with climate change, and the stronger storms that are produced, in mind.
“If it hasn’t already happened to you, people have a hard time believing that it could, therefore the preparatory activities seem like a waste of effort,” warns Gilk. He acknowledges that healthcare providers have a lot of projects competing for time and effort, and that it’s easy for them to fall into the trap of not seeing disaster preparedness as the high priority it should be.
Each catastrophic event, however, is a reminder that disaster recovery should be a priority. Hurricanes, floods, power outages—all these and more can hamper normal operations and require contingency plans. Those unaffected by recent calamities should heed the lessons learned by those who were.
For those who were in the path of Sandy, the recovery is already well underway. Teahan says the key is not to look at it as a disaster, but to “ask ‘what is the first small step I can take tomorrow?’” HI