When Hurricane Harvey slammed into Texas three years ago, Gulf Coast hospitals strained to provide care while facing record flooding that, within days, swallowed a third of Houston.
Babies were plucked from neonatal intensive care units and flown elsewhere in Texas as offers of help poured in. But the enormity of the late-August 2017 catastrophe, coupled with the temporary closures of 20 Gulf Coast hospitals, left the region scrambling to care for storm-injured patients, people on dialysis and residents with nowhere else to go. Some hospital staff lost everything but stayed at work to care for their neighbors.
Those challenges underscored the importance of collaborating, communicating and planning for multiple disaster scenarios—all useful lessons for meeting a different but equally unprecedented calamity: COVID-19. Although an infectious disease pandemic and a natural disaster are very different, hospitals see overlap in preparedness and are applying lessons from one to the other.
When COVID-19 began spreading in Texas in March, “Nobody took it lightly. I think the disaster of Hurricane Harvey woke up a lot of people,” said Terry Scoggin, CEO of Titus Regional Medical Center in Mount Pleasant. “Hurricane Katrina changed the way Louisiana responds to natural disasters, just like Harvey changed the way Texas prepares.”
Then and Now
Like Gulf Coast hospitals bracing for Harvey, facilities across Texas planned for a surge of COVID-19 patients and evaluated access to supplies, staff and alternative sites of care.
Ensuring that vulnerable patients can safely maintain care in their homes is a critical part of being prepared and saving precious hospital resources, said Mary Dale Peterson, M.D., chief operating officer at Driscoll Children’s Hospital in Corpus Christi and president of the American Society of Anesthesiologists. “We start phone calling all of our Medicaid at-risk members, especially those who are technology-dependent, to make sure they have emergency plans,” she said.
Hospitals also need to assess their vulnerabilities and make backup plans. Dr. Peterson consulted with a White House task force on the COVID-19 pandemic and realized severely inundated hospitals in New York City would have benefited early on by knowing which nearby hospitals still had beds. The New York Times reported May 14 that the city’s hospitals, used to going it alone, did not have a way to match patients to beds in other networks. As the surge continued, they cobbled together a daily map, showing conditions at each hospital, and leaders of New York City's five largest systems started meeting every other day, the Times reported.
“You have to learn to share resources,” Dr. Peterson said.
In Texas, communities often share. During Harvey, Scoggin’s 108-bed hospital wasn’t affected, so, the local fire chief, along with several trucks, traveled to Houston to help. Anticipating COVID-19, Scoggin knew he could call on Dallas hospitals to assist with a patient surge, but what if they were also full?
Scoggin opened an unused floor and reserved it for COVID-19 patients. He also identified a school, the civic center and a shuttered hospital as potential care sites. So far, those outside locations haven’t been needed, but Scoggin can rest easier knowing a plan’s in place for the five counties and 82,000 residents who depend on Titus Regional.
He also took painful steps early on to secure his hospital financially, which he had estimated could lose $7 million from the pandemic. Because COVID-19 threatened to be the final straw for some revenue-strapped rural hospitals, Scoggin said he consolidated clinics and suspended some services. On April 1, about 80 employees—between 10% to 12% of the workforce—were laid-off or furloughed.
“Emergency planning wasn’t just PPE and people. It’s also financial,” he said.
To mitigate losses, Congress allocated $175 billion for hospitals and other providers. Also, lawmakers appropriated $10 billion to rural hospitals and clinics, including $634.4 million for Texas, which received the most of any state.
“The federal stimulus will have a huge impact on our health system financially,” Scoggin said. “The stimulus and the cost reductions should minimize our net loss impact to several hundred thousand dollars, as long as the recovery phase stays on track.”
Communicating and Coordinating
Dr. Peterson said Harvey demonstrated the importance of activating an incident command center so hospitals, emergency providers and others could easily communicate and track what was happening. Texas is fortunate, she and others said because it has Regional Advisory Councils that oversee the statewide trauma system and help communities coordinate emergency medical services.
“It’s invaluable,” Alex Arroliga, M.D., chief medical officer of the Baylor Scott & White Health system, said of the RAC. “It’s almost like having a periscope. You look around and can see. It’s easy to get lost in your own thing.”
In addition to assisting with communications, various RACs also distribute personal protective equipment through the Strategic National Stockpile. With COVID-19 circulating, Baylor Scott & White communicates closely with the RAC, state and local officials, public health authorities and other hospital systems, Dr. Arroliga said.
Internally, he is on a call three times a week to discuss COVID-19 updates with medical directors and other staff at Baylor Scott & White hospitals. That may sound like overkill, he said, but “We prefer to err on the side of being over-prepared rather than under-prepared.”
Marc Boom, M.D., CEO of Houston Methodist’s eight hospitals and chair-elect of the Texas Hospital Association’s board of trustees, said his system created a centralized communications command during Harvey and redeployed it during the pandemic. “In this disaster, we recognized this was a command and control approach,” Dr. Boom said. If one hospital was inundated and needed PPE and staff, the command could quickly identify another that could help.
With the 2020 hurricane season now in progress through Nov. 30, those incident command centers could do double-duty, juggling COVID-19 admissions with a simultaneous surge in storm-injured patients. Because COVID-19 is so contagious, isolating infected individuals adds a significant challenge to hurricane preparedness work.
“As in every year, we have assigned our employees into ride-out and recovery teams and have even started to think through where we can sleep our ride-out teams who now need to be socially distancing,” said Roberta Schwartz, executive vice president of Houston Methodist Hospital. “If we need to be a receiving hospital for COVID and non-COVID patients above our current level, we will use our incident command to titrate all other services to be able to accommodate the needs of the community.”
The Federal Emergency Management Agency issued hurricane guidance in May that urges hospitals in hurricane zones to have plans not only for moving patients out to alternative care sites but also for moving ventilators, dialysis machines and PPE. Screening staff and patients will be essential to reduce virus spread, FEMA said, adding that it would work with communities to shelter patients who need to be isolated but not hospitalized.
The Psychological Toll
Responding to a hospital’s physical needs is one thing; offering emotional—even financial—support to staff is another priority, Dr. Boom said.
“One thing that became very clear during Harvey was the emotional and psychological toll it was taking on the staff, many of whom were working when their spouse called to tell them their house was flooding,” he said. “It was incredibly difficult psychologically for people to go to their home disaster and then come into work. And it was incredibly difficult financially for those individuals.”
Houston Methodist set up a relief fund and distributed millions of dollars to staff during Harvey. When the COVID-19 crisis hit, officials offered spiritual and psychological counseling, in addition to providing financial help to those not getting their usual pay.
“We wanted to do everything we could to take that source of anxiety out,” he said.
Another lesson from Harvey was using telemedicine to assist patients who were trapped at home and couldn’t get to a care site. Houston Methodist’s use of telemedicine has since exploded. It developed a “virtual ICU” to monitor COVID-19 patients and consult with staff, directly from the patient’s room. A nurse, for example, can push a button, enabling sight and sound in the room, getting guidance 24/7, Dr. Boom said.
“We can also do more routine care and help families communicate with their loved ones,” he said. “We will learn many lessons from this.”
Scoggin held virtual town hall meetings to answer COVID-19 questions from the community and share information. It was so successful he plans to do more. “Everybody who was timid about using ‘tele’ for anything, it (COVID-19) has ripped the Band-Aid off.”
After Harvey, THA worked with the Texas legislature to fix some problems that had cropped up, said Carrie Kroll, THA’s vice president of advocacy, quality and public health.
A 2019 law eliminates the worry of a lawsuit for health professionals who volunteer during a disaster. Another establishes access to the state’s immunization registry, so first responders who may not know their vaccination status can check the registry or allow their employer or supervisor to do so. That avoids wasting precious resources during a disaster.
Still unaddressed, Kroll said, is a larger question that arose during the H1N1 flu pandemic of 2009 and has reemerged: the need for crisis standards of care, which establish a process for hospitals to determine how to allocate scarce resources, such as ventilators to patients.
“After H1N1, there was a national movement to put crisis standards of care in place,” Kroll said. “If you’re a patient and if there are not crisis standards of care in place, you don’t know if you’re going to be treated differently walking into one hospital versus another.”
No such standards have passed in Texas, but she expects some advocates to raise the issue during next year’s session in light of the life-and-death decision-making COVID-19 has provoked. “It is sure to be a lively conversation,” she said.
Lessons from Ebola
When the first Ebola patient came to the U.S. in 2014—to a Dallas facility—hospitals across the country sought ways to enhance and expand patient isolation rooms.
Houston Methodist converted an old hospital ER into a six-to-eight-bed unit for highly infectious disease cases, Dr. Boom said. Although it wasn’t needed then, space remained, and when hospital officials saw what was happening in China in January, they expanded it to accommodate dozens of COVID-19 patients. Dr. Boom said they asked for staff volunteers to work in the unit and hoped it would hold all of Houston Methodist’s COVID-19 patients.
Houston Methodist also had been stockpiling PPE before COVID-19 hit, but that, too, wasn’t nearly enough, he said.
Learning on the Fly
Hospitals nationwide have struggled to obtain sufficient PPE, test kits, hand sanitizer and ventilators, especially in hard-hit COVID-19 areas.
“Whether from COVID or planning for a hurricane, we are trying to keep adequate to generous par levels, but all hospitals have been on ‘allocation’ for many months now for PPE,” Dr. Peterson said. “We are still in our conservation mode with reuse and resterilization of N95s.”
Priority needs to be given to fixing the supply chain, said Bob Bonar, professor and director of the Master of Healthcare Administration Program at The George Washington University and former CEO of Dell Children’s Medical Center in Austin.
“We need to look at regional or state level processes for an intelligent supply chain process to provide PPE,” Bonar said. “You need to get away from these silly things we’ve done in COVID-19 with one state outbidding another state for PPE.”
Bonar and hospital executives say the struggle for essential supplies is a loud wake-up call to state and national leaders. “If this has shown us anything, it has shown we have underinvested for two decades in public health,” Bonar said.
Historical data bear that out. Federal dollars to support the Public Health Emergency Preparedness program and the Hospital Preparedness Program have fallen sharply since their funding heydays after the 9/11 terrorist attacks. Nationally, federal dollars for PHEP went from a high of $940 million in fiscal year 2002 to $675 million in FY 2020. Likewise, the Hospital Preparedness Program went from $515 million in FY 2003 to $275.5 million this fiscal year.
Texas state government also hasn’t been overly generous to public health. It allocated $491 million in FY 2019, far behind the $2.8 billion California invested and below the amounts of two smaller states: $1.6 billion in New York and $574 million in Massachusetts, according to the Trust for America’s Health.
Dr. Peterson said she hopes a silver lining from the COVID-19 experience will be addressing shortages of PPE, testing supplies and common drugs. Scoggin said he believes Texas hospitals will be better prepared for future waves of COVID-19 because of lessons they are learning now.
“If it happens again,” he said, “we won’t have to recreate the wheel.”