Doctors who have lived through natural disasters advise their peers it’s impossible to over-prepare
Physicians might seem among the best-equipped people to deal with the harrowing and unexpected nature of emergencies, from manmade calamity to natural disasters.
However, research shows that many physicians are not as prepared as they could be. According to a 2015 study in Disaster Medicine and Public Health Preparedness, fewer than half of 1,603 practicing physicians interviewed felt prepared to handle a natural disaster. Additionally, less than one third signed up to receive mobile alerts for future emergencies with local and federal agencies.
“Where I see practices being successful is when they make emergency preparation an ongoing part of their operation, and they realize the importance of business continuity,” says Molly Evans, JD, Washington, D.C.-based principal with the law firm Feldesman Tucker Liefer Fidell LLP, and an expert in CMS emergency preparedness rules.
Consider the experience of Jeff Giullian, MD, chief medical officer of hospital services for DaVita Kidney Care in Beaumont, Texas. When he heard of the threat of Hurricane Harvey in August 2017, his institution’s risk assessment made him aware that such a storm could threaten dialysis operations, which rely upon fresh, clean water for the procedure.
“We were able to start planning on the outpatient and inpatient dialysis side, [and] start working with our internal emergency management team to look for resources ahead of time,” he says.
When the storm caused a water outage, DaVita’s preparation made it possible to obtain special dialysis machines that run on prepared bags of water, and to train nurses and technicians on how to use them within 48 hours.
“Had we not had those brainstorming sessions on Friday we wouldn’t have been ready to hit the ground running on Saturday, and dialyzing patients by Monday,” Giullian says.
While CMS requires any practice or hospital that serves Medicare or Medicaid patients to comply with its new Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, state and local laws vary widely or may be vague, which may leave physicians waiting until after disaster strikes to put together a plan. However, Evans feels it would be a mistake for a practice to minimize the importance of emergency preparation.
Weigh the risks
For instance, practices on the east coast are more likely to face hurricanes and tornados, while those on the west coast may expect earthquakes, wildfires, and mudslides. However, unexpected situations could affect any practice, ranging from fire to network communications failures to active shooter situations.
As part of a risk assessment, Evans suggests developing relationships with local law enforcement agencies so that practices are not figuring out who to call in the middle of a crisis. She also recommends that physicians take advantage of checklists and recommendations from emergency management organizations such as the Red Cross, FEMA, and OSHA.
Lastly, don’t forget about the legal liabilities of emergency preparation.
“A failure to have a comprehensive emergency plan in place could definitely lead to heightened liabilities,” says Diane Doherty, MS, a former hospital risk manager and now senior vice president of Chubb Healthcare, which insures healthcare institutions. She recommends physicians look to their insurance carrier to conduct risk assessments and help train staff.
Plan in advance
The first thing physicians need to do after developing such a plan is to decide who is going to be responsible for implementing that plan, suggests Doherty. “You want to make sure the staff is educated about whatever policies you’re putting into place,” she says.
Joshua Weil, MD, assistant chief of hospital operations, and an emergency physician for Kaiser Permanente Santa Rosa Medical Center, in Santa Rosa, Calif., evacuated his hospital in October 2017, when wildfires devastated parts of northern California. He was grateful for the annual drills and practice runs.
“The more planned and prepared you are, the easier it is not to panic,” he says.
Weil reported to work in the emergency department just after midnight, with the scent of smoke heavy in the air. Accustomed to wildfires at that time of year, he didn’t think much of it until he overheard the chatter of fire-related injuries on the paramedics’ radios as they came in and out of the ED.
By 1 a.m. the ED was becoming chaotic and Weil made the call to open a command center, “a structure we have for managing crisis that can be anything from a power outage to equipment failure to something large scale like this,” he says.
He called in as many extra staff as he could get. At 2 a.m., when the fire commander on the scene told him the fire was just 200 yards away from the hospital but was not suggesting that evacuation was necessary yet, Weil made the call to evacuate all 122 patients from the hospital and ED anyway. “In retrospect, it was clearly the right decision, as all major roads to evacuate by grew increasingly dangerous with fire and smoke, but in the moment I was thinking ‘I’m going to get in a lot of trouble for this,’” he says.
Weil credits quick thinking, prior drills, and a culture of “collegiality and cooperation” in which staff were all able to put aside hierarchy in favor of doing what was right for the patients, for the relatively smooth and quick evacuation.
Communication is key
“You want to know how you are going to get in touch with your staff when you are facing an emergency, and how you’re going to communicate externally with the local, state, and even federal emergency response personnel,” Evans says. In emergencies, particularly natural disasters, it’s easy to lose power and thus networks, threatening communications. Evans says it’s important to have backups.
In June 2015, a severe storm took down the computer network of Jefferson Health, in Cherry Hill, N.J., disrupting all the system’s operations. The network is a key part of patient care. “We document in their chart, place orders, review results and look at X-rays all electronically,” says James McCabe, MD, chief medical information officer.
He needed to get the word out to his staff all at once, particularly front-line staff such as physicians, nurses, x-ray technicians, and physical therapists. Fortunately, they had begun using a text messaging app called Tiger Connect that allows clinicians to text or message each other securely.
Through the app, which works on both Wi-Fi and cellular signals, he was able to message all staff members at once about the network disruption. And they were then able to relay news of the outage and its disruption to their patients.
“At the debrief, everybody spoke up about how great it was to really be able to get quick communication out through this messaging application,” McCabe says. Being able to message everyone simultaneously was especially valuable because it saved time and mitigated some frustrations.
Keep patients informed
“It was a way of helping our patients have access to some kind of medical care so they didn’t feel like they had to run to the ER in the middle of the storm,” Millon says. He was able to reassure one mother not to rush her baby to the ER, and encourage another patient to go before the storm grew too intense.
His only regret, and something he aims to learn from, is not checking in on his most in-need patients in advance. “I’m going to keep a running list of my sickest patients, because I had a couple of patients who went to the hospital probably unnecessarily because they were nervous,” he says.
He’s also looking for a way to contact patients via text message instead of email for the future, because it’s a quicker and more effective way of communicating.
Stay flexible and creative
When they were about to begin evacuations, because tracking patients turned out to be very challenging, he says, each patient was assigned a staff member to make sure they weren’t declining or in crisis. As they were evacuating, one of his colleagues suggested using their iPhones to take pictures of each patient’s wristband as they were leaving the hospital. After evacuation, they reconciled their lists of patients who had been in the hospital with where they had landed to make sure everyone was accounted for.
He also recommends, when possible, partnering with other clinics, practices, and hospitals, especially if patient care is interrupted. With some 5,000 homes destroyed in the wildfire and evacuees fleeing with only minutes to spare and the clothes on their backs, Kaiser staff realized they would need to help patients refill medications and other prescriptions quickly. They worked with neighboring pharmacies to help patients fill prescriptions in a way that didn’t require them to come up with large sums of money out of pocket.
Millon was able to offer his offices to a neighboring pediatrician who lost power for four days in Hurricane Irma, and believes that it’s crucial for a practice to cultivate these relationships.
“You have to build trust ahead of time so that when a natural disaster hits, you can all row in the same direction,” Millon says.
He is convinced that his good relationship with the local hospital, with supplies vendors and physician leadership made everything go as smoothly as it did.
“The time and effort you put into the routine day to day relationships pays dividends during an emergency.”