Nov
09

Open letter to all those Leadersᶼ with Oversight Responsibility for Public Health and Healthcare All-hazards Readiness

ᶼ Congressional, DHS, DHHS, OSHA, EPA, NRC, DOD, DOE, State, Local, Tribal, Territorial and Oval Office, Healthcare Corporate Boards/Trustees, Hospital C-Suite

Why Hurricane Sandy’s response looks like the Hurricane Katrina’s response

My first observation is that “Lessons Learned (LsL)” is more myth than reality. Prior to Katrina’s landfall the state and city decision makers were armed with one of history’s most spectacular set of “LsL” from the adjoining state of Texas.  Tropical Storm Allison (TSA), 2001, devastated the city of Houston’s Healthcare System; the world’s largest hospitals and the healthcare system were swamped by flooding of its normal and emergency electrical utility supply. The hospitals had to be evacuated in darkness and 100-degree temperatures. Ninety thousand research animals were killed and thousands of research specimens were lost forever representing decades of medical research.

Three years later the Southeastern Louisiana Emergency Exercise (PAM) was tasked to forecast the effects of a slow moving category 3 hurricane on the region in general and New Orleans in particular. Tragically the forecast was almost a clone of what was to become killer Katrina.

A year later hurricane Katrina roared into the Gulf its potential landfall was within 100 miles of the New Orleans Metropolitan Area, little surprise since category 3+ storms had taken that path 12 times in the last 100 years. State and local civil and healthcare authorities followed the approaching storm on an hour-by-hour basis for days. Earlier hurricanes’ with the perceived destructive power of Katrina called for evacuation of hospitals and nursing homes.

The decision to “Protect in Place or Evacuate (PiPE)” is viewed by civil and healthcare authorities as a “life or death” action. This critical set of actions must be executed in a timely and thoughtful manner. As the environment of care changes these decisions become more complex.

A generation ago hospital boards and C-suites were populated with local business and professional leaders. The patient populations were more diverse and typical hospital stays were lengthy. Today’s hospital census is a concentration of very sick (acuity) patients. This has dramatically reduced the number of patients who may be discharged to home or other locations in times of crisis. The new strategies associated with a “just in time paradigm” is economically desirable, however, it adds new and significant challenges for decision makers. The costly operation of organic warehousing and related rolling stock and staff reduces the hospital’s capacity to “protect in place or Evacuate”.

Paramedics evacuate patients from New York University Tisch Hospital due to a power outage as Hurricane Sandy makes its approach in New York - REUTERS/Andrew KellyIn earlier times Administrative and Clinical functions were organic to the healthcare organization. The dramatic shift to “Outsourcing” of the functions has added challenges for hospitals to execute their PiPE decisions. The food service contractor may have made the same commitment to support other customers with their finite assets (over-subscription), the buses promised to evacuate your patients and staff may be committed to others as well. Availability of current temporary clinical and administrative personnel may also be in multiple organizational emergency disaster plans.

What happened when LsL are not learned or ignored?  State and local civic and healthcare authorities failed to mitigate known vulnerabilities associated with the potential for flooding and breached levees. An environment of apathy and denial dominated the decision making process. Congressional and federal administrative leadership failed to intervene, despite their duty to do so; all appeared to be mesmerized by overwhelming evidence that a tragic natural disaster was unfolding before their eyes. The fateful decision was to “protect in place”.

All of the hospitals and nursing homes proudly displayed objective evidence that they were prepared to deal with the greatest natural hazard in the region. The Department of Health and Human Services Center for Medicare and Medicaid Services (DHHS-CMS) had funded external evaluation mechanisms to ratify that these organizations were safe and secure loci for the trusting public. The new Department of Homeland Security (DHS) in partnership with DHHS is designed to ensure that the nation’s Public Health and Healthcare sector is a meaningful player in the country’s strategy for Homeland Security. In reality neither was effective when needed.

The final count of Katrina related deaths in the New Orleans Metropolitan Area (NOLA) was 971, thirty-four percent (34%) of these bodies were recovered from hospitals and Nursing homes (334).

There are some who think that the lucky victims were in Nursing Homes whose deaths were quick albeit horrific. The frail elderly, many on life support systems, experienced slow agonizing deaths as utilities failed and exhausted caregivers could not keep them alive; and many in nursing homes drowned in their beds and wheelchairs as water filled the facilities.  The physical and psychological toll on those caregivers trapped in disintegrating facilities desperately struggling to save their dying patients may never be known.

Eleven years after Houston’s Tropical Storm Allison and seven years after preventable deaths of hundreds of the most vulnerable among us, we find that Hurricane Sandy found a Public Health and Healthcare sector unprepared to meet their duty to a trusting public.

The specter of National Guard troops working in darkened hospitals evacuating frail elderly and neonatal patients going in one direction and troops with 5 gallon fuel cans going in the other direction to feed the emergency generators is mind-boggling.

NYC Belleview Evacuation - ABC News PhotoIf one is to believe press reports it appears as if both mayors, NOLA and NYC exempted the hospitals from mandatory evacuation in the case of Katrina and Sandy. The location of emergency generators or electrical switches below the flood plain is similar. New Orleans did not learn or ignored from Houston and NYC did not learn or ignored events from Houston and/ or NOLA. The conflict between national, state and local regulation dealing with the location of electrical switching stations is troubling. The “Irene effect”- evacuating  only to find it was overkill- and the earlier experiences in NOLA evacuating hospitals only to find that it was a not necessary and was an economic burden. The landfall predictions, days in advance, for both hurricanes were accurate.

Perhaps the optimistic headlines from DHS and DHHS in the spring of 2011 “MAJORITY OF U.S. HOSPITALS MEET ALL-HAZARDS PREPAREDNESS MEASURES” was premature or misguided. What if those who would do us harm used the “fog of response” associated with “Sandy”? Is there a hospital in the nation ready to repel a “Mumbai-like” attack?   It has been eight years since the American College of Healthcare Executives (ACHE) announced that hospitals were prepared to deal with the “Bioterrorism threat”, which was premature. The proliferation of bio labs across the nation has increased the potential for both inside and outside bio-terror or bio-error risks. Dangerous bio agents, toxins and Medical Use Radioactive Material (MURM) have not been satisfactorily accounted for in the aftermath of Allison and Katrina.  Did we have anything disappear in NYC during Sandy that might be useful to those who would do us harm?

Hospitals and Nursing Homes are very dangerous places to work. Female caregivers are the most abused and assaulted group in the nation’s workplace. Violence in healthcare continues unabated, patient on staff, staff on patients, staff on staff and off-the-street miscreants.

The Public Healthcare System is purported to be the most regulated industry in the country; subject to oversight from Congressional, multiple Federal Agencies, State and Local Regulatory Agencies yet no one appears to be in control. And empirical evidence shows that in life threatening events, decisions to rely on unprepared hospitals has continued to put patients at risk. How can you move the generator to the 14th floor and leave the fuel source at floodplain level?

In Public Healthcare, the sham of external accreditation that certified all the “Allison”, “Katrina”, “Irene” and now “Sandy” hospitals, allowed Risk Managers to wash their hands and corporate boards to make actuarial decisions that caused preventable loss of life and injuries in our hospitals. Application of the general principles of Risk Management dealing with healthcare is very complex (ethical, moral and legal); we have to ask ourselves if there is a place in Healthcare delivery for a level of risk acceptance that includes known potential loss of life when dealing with hospital and nursing home populations.