As Hurricane Harvey struck the Texas Gulf Coast as a Category 4 storm Aug. 25, 2017, Texas hospitals braced for impact. Steadied by more than a decade of preparation taken from lessons learned in Tropical Storm Allison in 2002 and Hurricane Ike in 2008, hospitals leaders and frontline caregivers largely kept the hospital industry intact to care for thousands of patients in need.
Few expected that the storm would bring four more days of record rainfall across the Texas coast, causing extensive flooding. The ongoing demand for services from patients otherwise served by a community of clinics and specialty centers spiked for hospitals, and the window of time for preparation began to close as unexpected needs arose.
A unique apparatus provided a collaborative and coordinated response that outperformed expectations set by previous hurricane disasters along the wider Gulf Coast multistate region. Organizations like the Texas Hospital Association worked closely with regional stakeholders and government agencies while a system of regional advisory councils readied transportation units and a reserve supply chain.
Long-term impact on hospitals varied. Many appeared unscathed while others went through quick maintenance and repair operations. East Houston Regional Medical Center ceased operation entirely. Care Regional Medical Center in Aransas Pass, between Mustang Island and San Jose Island, still had not reopened as of July 7, 2018. Most facilities, however, remain in operation. That such a large-scale disaster set itself in a geographically vulnerable location for almost a week is a testament to the resolve that is almost impossible to relate.
Despite the success of the response, hospital leaders are still collecting a reserve of take-aways to inform how future administrators should prepare. Hospital leaders recap lessons learned with perspective gained over a year.
Meeting New Challenges
“This is the first time we had remote facilities that remained open during a storm,” said David Marshall, NP, J.D., RN, vice president and chief nursing and patient care services officer for The University of Texas Medical Branch Health.
Harvey reinforced the need for improved communication and transport between UTMB’s five hospitals and 90 clinics, after flooding caused one hospital to become an island accessible only by boat or military high-water vehicle. UTMB has since purchased a boat for transporting supplies and personnel in emergencies.
As community clinics became disabled, patients depending on local dialysis facilities began looking for care. To accommodate walk-in dialysis patients, UTMB extended in-house dialysis unit hours until 11 p.m., and made adjustments as conditions evolved. “We were able to expedite them through our ERs and do their dialysis in-house under a waiver from (the Texas Health and Human Services Commission),” said Marshall. “We've worked with the Galveston County health district and local outpatient dialysis providers to try to be better prepared for it in the future.”
During the height of the storm and flooding, most of UTMB’s ambulatory care sites were closed and elective surgeries were postponed, causing an initial revenue impact that was felt almost immediately. Revenue issues lingered well after the storm as well as many UTMB patients deferred elective care, surgeries and procedures.
Dialysis Overload and Pharmacist Shortage
Janet Leatherwood, RN, vice president/chief nursing officer at Houston Methodist Sugar Land Hospital, also found that demand for dialysis exceeded capacity. “At one point we had 50 patients in our hospital emergency department that needed dialysis,” she said. Not only were local dialysis units closed, but discharged patients could not find available pharmacies to fill prescriptions.
“At one point we had some of our staff navigating the flooded roads to pick up a pharmacist to assist in addressing these needs. It was a huge stress trying to find a pharmacist that we could bring in for the community,” Leatherwood said.
In addition, the hospital was getting requests for baby formula and supplies. So, when another local hospital was about to close inpatient operations, “we asked them to give us their dialysis supplies and baby formula so we could manage the surge of patients and families asking for assistance,” she said.
After Harvey, Leatherwood and her colleagues began working collaboratively with local dialysis centers and pharmacists to create a proactive plan to address patients’ needs prior to the next emergency.
“When you have thousands upon thousands of Houstonians calling 9-1-1 for rescue from their flooding home, it's hard to say, ‘there are children out there that really need to be at the top of that list’,” said Brent Kaziny, M.D., medical director of emergency management for Texas Children’s Hospital.
Fortunately, the hospital worked in advance to prepare patients to either ride out the storm at home or evacuate safely. “Hurricane Harvey pointed out the importance of those plans,” said Kaziny. “For example, our renal team brings dialysis patients in and provides dialysis prior to the hurricane, even if they don't necessarily need it, to make sure that they are able to last longer after the events and to provide a bag of supplies and information on what their fluids should look like and some of their medical issues.”
“Initially we had issues not so much on the hospital side, but with communications with the city and Red Cross, as far as which shelters would be appropriate for children with complex issues,” said Kaziny. “We now recognize a need to aggressively investigate that prior to an event like this happening.”
“This storm was devastating,” said Ericka Brown, M.D., chief operating officer of Harris Health System, which faced episodes of flooding and various facilities problems. Preparation from teams and their planning for such an event limited the damage, said Brown. “Right after the storm is not the time to be looking for contractors,” she said. “We were fortunate to have those relationships in place prior to the hurricane. During Harvey we had recovery services with us in house. They helped us mediate issues as they were happening. They helped dry out our lower levels and remove any wet drywall.”
To make it easier to bring in medical relief personnel, “we've been working on issues like improving the volunteer registry,” said Carrie Kroll, vice president advocacy, quality and public policy for THA. During and following the storm, volunteers poured in through a variety of sources. While hospitals attempted to maintain services, organizations like THA and government agencies attempted to maintain a clear process for managing clinical and non-clinical volunteers. The resources needed to manage that demand while also outlining clear processes for maintaining the information are currently under review for future disaster management operations.
THA is also exploring legal implications of volunteering. “Depending on whether you work for a public or private facility, and where you are volunteering depends on whether you're actually covered by the Good Samaritan law,” Kroll said. As a result, the THA legal team is identifying where holes in liability coverage exist to create legislation in 2019 to protect for institutions that use volunteer support during a crisis. Kroll said THA’s solutions in this area will include collaboration with the wider community of associated health care stakeholders like the Texas Medical Association and others.
“We believe that everyone that wants to volunteer during a disaster should have the same level of coverage,” Kroll said.
Texas Children’s Hospital, Houston, has “a pool of 3,000 employees who've agreed, in the event of something like a hurricane, to see to it their families are taken care of in advance, so they can be here to provide whatever services need to be provided,” said James Mitchell, assistant director of emergency management and business continuity. One take-away from Harvey, he said, is “we think a hurricane is going to be done in two days, three days, maybe four at the most, and so one of the things that really struck us is that the reality of a five- to six-day event is something that we do have to plan for.”
After Harvey, the organization also has prioritized aligning medical and support departments — getting clear data from the medical team, types of medicine, number of physicians expected on hand during an emergency, and contact information, so they can communicate in a unified voice to staff and physicians. Their critical event communication management platform helps, said Mitchell. “That enables us to reach out to every single contact method that somebody has defined, whether it's their cell phone, text, home phone, email, personal email. That system enables us to communicate extremely efficiently in the midst of an emergency.”