3
Learning from Experience
The workshop’s third panel session presented some lessons learned from the past that might guide subsequent discussions on what form public–private collaborations should take. Ricardo Martinez from Adeptus Health moderated this session, which included presentations by Scott Cormier from Medxcel Facilities Management; Karen DeSalvo from the University of Texas and formerly from the New Orleans Health Department; Erin Erb from the Gulf Coast Division of the Hospital Corporation of America; Todd Sklamberg from Sunrise Hospital and Medical Center; and Richard Zuschlag from Acadian Ambulance Service. An open discussion followed the five presentations.
CASE STUDIES IN CROSS-SECTOR COLLABORATION FROM PAST DISRUPTIONS
Scott Cormier began his presentation by explaining that Medxcel is part of Ascension Health Care, the largest not-for-profit health care system in the country. He mentioned this because large health systems such as Ascension, HCA, Kaiser, and the VA have a great deal of experience in emergency management. “If you have one disaster a year at your hospital, and that is a lot, in 10 years you will go through 10 disasters,” said Cormier. In that same 10-year period, Ascension will go through about 1,500 disasters. “Last year,” he noted, “we had 96 incident command activations, and it is this experience that leads the way health care systems respond to disasters.” In fact, added Cormier, he has asked the American Public Health Association to bring the large health systems together to pool
their knowledge, which he believes would have a dramatic effect on large-scale disaster response. Besides knowledge and experience, large health systems are self-sufficient, which means they will be less likely to draw on resources from the community and should be able to contribute resources and expertise to their communities.
According to Cormier, Ascension’s emergency management program is unique in that it combines safety and emergency management as a means of bringing value to emergency management and spare it the occasional budget cuts that can happen when there have not been any disasters in the immediate past. He explained that all of Ascension’s safety and emergency management people are under his chain of command and that there is a virtual emergency operation center he and his staff use to manage disasters from the very beginning. “It is not the typical model of ‘good luck, God bless, hurricane’s coming, if you need help, call us,’” he said. Rather, his group is part of the planning process at every Ascension facility, and the organization has national contracts with meteorological companies, generator companies, and supplies so that the organization is a self-sufficient entity when disasters strike.
He and his regional directors also stay in regular contact with state and federal partners, creating established two-way information conduits for when the need arises, as well as with Ascension’s senior executive, both in times of calm and during a major event. “Once or twice a day during a major event, we will send senior management a very high-level update about what is going on, and they trust us to manage the incident and do the right thing,” said Cormier.
Ascension has 12 hospitals in Texas, mostly located in the Austin area, and while there was some flooding and water damage during Hurricane Harvey, those hospitals served as receiving facilities for people evacuated from southeastern Texas. He noted that he was in contact with his friend and colleague Michael Wargo from HCA throughout Hurricane Harvey to make sure the two systems coordinated their activities. “I call that muscle memory communication,” said Cormier, who joked that half of his salary pays him for his extensive contact list. “Being able to make those phone calls and share information or get resources is crucial. That is how we solve the communication problem during disasters, and we need to develop better muscle memory communication,” he said.
One of Ascension’s resources is its subscription to a private meteorological service whose models incorporate the physical location of all of Ascension’s hospitals and some of its secondary sites. As a result, the weather reports it receives are detailed to the point that they can pinpoint the time and location of weather events that could affect specific locations in the Ascension system. This tailored and accurate information was crucial during Hurricane Harvey because the local and national weather reports
were more spectacular than useful. “Emergency management becomes the source of truth during a disaster,” said Cormier. “We saw that with H1N1 [influenza], we saw it with Ebola, and we saw it with the hurricanes. People depend on us to be that single source of proper information. We see that as a key role, so we make sure we are communicating that information regularly.”
As an example, he recounted how during Hurricane Irma, the Jacksonville Fire Department came to one of Ascension’s nursing homes and said it was there to evacuate the facility because reports were calling for the St. Johns River to rise 5 feet, which would have devastated the nursing home. Cormier called the local incident commander and told him that he had reports that projected that the river would rise no more than 30 inches and that he was prepared for that event. After some back and forth, the incident commander deferred to Cormier’s better information. In the end, the river rose 28 inches. The same type of situations arose during the 2009 H1N1 influenza pandemic and 2014 Ebola outbreak, when the state health departments across the country were asking Ascension to do things outside of its scope of what CDC was recommending and what his system’s best practices were. “We said no, and that is an important part of our program,” said Cormier. “When you are the holder of the truth, that is what you need to do.”
Cormier noted that the federal government was extremely helpful during Hurricane Irma by supplying platelets, which enabled Ascension’s three Jacksonville hospitals to keep its surgical facilities open and operational. ASPR held daily conference calls during each of the national emergencies in 2017 through the Health Care and Public Health Sector Coordinating Council.1 Cormier stressed the importance of being a member of the council. His team also worked with the Federal Bureau of Investigation (FBI) during the Austin bombings and is a member of a workgroup formed in 2013 to provide guidance on how health care systems can plan for and respond during an active shooter incident.2
Going forward, he said, one area that needs more work is how to leverage private-sector expertise with a federal response more effectively. As an example, he noted that his organization has expertise on how to restore a hospital after a hurricane, and yet nobody from Ascension is in Puerto Rico helping the island restore its hospitals. “Why is the private sector excluded from the Center for Homeland Defense and Security master’s program?” he asked, noting that only government employees can participate. “Wouldn’t it
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1 See https://www.phe.gov/Preparedness/planning/cip/Pages/partner.aspx (accessed April 23, 2018).
2 See https://www.fbi.gov/file-repository/active_shooter_planning_and_response_in_a_healthcare_setting.pdf/view (accessed April 23, 2018).
be great to share our information with the classmates and learn what is going on in the government sector?” Another area that requires more thought, he said in closing, was mental health as an emergency management problem given the preponderance of mass shootings.
New Orleans’s Katrina Experience
In 2005, Hurricane Katrina became the costliest storm in the nation’s history, killing some 2,000 people and destroying infrastructure across the Gulf Coast. As Karen DeSalvo noted, the hurricane missed New Orleans, but the city’s flood wall system failed and 80 percent of the city—a land mass equal to the size of Manhattan—was flooded. In the flood’s aftermath, New Orleans was in a mandatory evacuation scenario for 30 days, and the city’s entire health care, public health, and emergency response systems were severely compromised. DeSalvo explained that despite the evacuation order, tens of thousands of people remained in the city.
In the days immediately after Hurricane Katrina, no resources were available to provide medical care. The private sector rushed into that void to establish a set of makeshift sites around the impacted areas of New Orleans, as well as across affected areas along the Gulf Coast. For example, Tulane Medical School, where DeSalvo was on the faculty at the time and which was an HCA facility, set up urgent care stations where volunteers could give tetanus shots, provide emotional support to people coming to these stations, and fill prescriptions (DeSalvo, 2005). Most of the federal and local resources that eventually came into play were stood up in places such as Baton Rouge and Houston, where the bulk of the people had evacuated, she said, adding that DoD proved to be an extraordinary resource during this catastrophe, erecting portable field hospitals.
In the months after Hurricane Katrina, health care officials in New Orleans began thinking about how to build a more resilient system. One realization was that New Orleans had a very centralized health care system, said DeSalvo, with about 30 percent of the city’s population receiving care at the city’s Charity Hospital, which was also the city’s level one trauma center, a major training ground for providers in the community, and an important source for outpatient care (DeSalvo, 2006). “We did not want to be back in a situation where when one hospital flooded, we are pretty well knocked out of the game, even with private hospitals able to stand back up more quickly,” said DeSalvo. The remedy for New Orleans was to create a more distributed network3 grounded in public health (DeSalvo and Kertesz, 2007). The city also worked to change financing so that people had portable insurance coverage that would enable them to receive care in other
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3 See http://504healthnet.org (accessed April 23, 2018).
communities, and it digitized the care experience so that providers would not be left guessing about people’s medical histories.
Thirteen years later, she said, New Orleans has built a more resilient health care system with these characteristics (DeSalvo, 2016, 2018). In addition, it has also reimagined how to build health care facilities that would be more resilient in the face of natural disasters, something for which HHS has since developed a toolkit (Guenther and Balbus, 2014). Hurricane Katrina also led to national changes, such as taking an all-hazards approach to planning and conducting drills. According to DeSalvo, the years after Hurricane Katrina have also moved the emergency preparedness field to engage in more cross-sector and agency-wide planning, and the federal government to establish a strong role and set of federal resources, including an incident command structure. The health care sector also moved from a reactive position to being more proactive not only with regard to planning, but also knowing that those who planned would be responding in the field. “There is an old adage in internal medicine that discharge planning begins at admission,” said DeSalvo, and New Orleans adopted that philosophy when it came to rebuilding its health care infrastructure and making it more resilient by design, which included making the entire community more resilient in the face of disaster.
One important lesson learned from the Gulf Coast’s experience with Hurricane Katrina, and one DeSalvo said was reinforced during the 2017 hurricane season, was that the social determinants of health, which are often affected severely in a disaster, have a disproportionately negative effect on communities of color, people with low income, and seniors. As a result, she said, “We cannot just pay attention to making certain they have good access to good medical care. We have to attend to the other infrastructure that will impact their lives, since so many are living on the edge every day.”
Human capital and capabilities cannot address all of those needs, said DeSalvo. “It is one of the reasons that we have as a country, and certainly in New Orleans, wanted to leverage data and technology to improve the effectiveness of response and recovery and resiliency,” she said. In addition to the widespread adoption of electronic health records, the past 13 years have led to a significant shift in how health care data are used during a disaster. For example, when she was the New Orleans health commissioner in the years after Hurricane Katrina, she led an effort to leverage claims data from Medicare to develop a tool called emPOWER. This tool, which ASPR and CMS now manage, allows health care to target the most vulnerable seniors and other Medicare beneficiaries in the community who will need special attention in a disaster.
DeSalvo noted that health care systems spend a great deal of time and money planning in the hospital system, but some of the most vulnerable people in the community are in nursing homes and community-based living
centers. The nation, she said, needs to make sure that there are incentives for ongoing partnerships and coalitions to help these other sources of care become more resilient. “We need more resilient communities, which means thinking about the social determinants of health,” said DeSalvo. To her, that also points to the critical importance of increasing the resources available to public health as a means of getting resources into the community as quickly as possible.
Lessons from Hurricane Harvey
When Hurricane Harvey hit Houston in 2017, it dumped more than 50 inches of rain, or 19 trillion gallons of water, on the region, flooding the city, its bayous, creeks, and homes, explained Erin Erb. Nineteen tornados touched down to the north, west, and east of the city, all while sustained winds of 130 miles per hour buffeted Houston and its suburbs. In total, some 120,000 people needed to be rescued, and the storm produced a projected $200 billion in damage to the region. Erb noted that for the HCA health care family and coalition members, it was time to pull themselves up by their bootstraps and come together.
HCA’s hospital in East Houston, the first to be evacuated, was built on a shipping channel and was destroyed by flooding. It will never reopen, said Erb. While the coalition was arranging to transfer patients, senior leadership in HCA’s Gulf Coast Division was already at work on a reunification plan that would detail how to transfer those patients back into the city once the flooding had cleared. She noted that throughout the hurricane, business went on as emergency operations and preparedness drills became real life and plans were enacted for getting personnel and material resources to where they needed to be, with help from HCA’s Nashville Emergency Operations Center, the Coalition’s Catastrophic Medical Operations Center (CMOC), and the SouthEast Texas Regional Advisory Council (SETRAC).
One lesson from Hurricane Harvey was the importance of mobilizing teams to serve as reinforcements. “Never in my life would I have been able to imagine the sheer depth and breadth of what it would take to have this response,” said Erb. By the time the hurricane had ended, 4 sister division emergency operations centers, 45 hospital command centers, CMOC, and 2 virtual transfer centers were involved in the response that involved 16 helicopters, 5 airplanes, 3 duck boats, 6 water tankers, 13 generators, and 82,000 gallons of diesel and gasoline. HCA marshaled out of its stores some 35,000 ready-to-eat meals, 6 days of linens, 2,000 20-pound bags of ice, 625 cots and air mattresses, 6,000 sandbags, and 120,000 bottles of water.
The response was tremendous, said Erb, but there were missed opportunities and lessons to learn. A serious challenge, for example, was coordinating air assets and landing zones throughout the storm, and com-
munication among the coalition members was spotty at times, which led to duplication of efforts. After the flood waters receded, HCA’s operating emergency departments were overrun by patients needing dialysis, highlighting the need to have a plan in place to address what was going to come after the storm. Erb explained that an additional lesson was to document everything that was happening as a means of informing postdisaster analysis. HCA learned, for example, that it needed to know the elevation of all its hospitals, the coordinates of its landing zones, and the location of each hospital in a specific flood plain. It also learned to invite its SETRAC coalition partners into its emergency operations councils so that they would be fully aligned for the next event. The final lesson, said Erb, was that the sun will rise again. In the end, she added, no patients, employees, or visitors were harmed.
Lessons from the Las Vegas Mass Shooting
Sunrise Hospital, said chief executive officer Todd Sklamberg, is the largest acute care hospital in Nevada, a regional tertiary center, and a level two trauma center. It is also among the closest hospitals to the Las Vegas Strip, so when he received a phone call at 10:20 PM on a Sunday evening that informed him of a mass casualty event, he went to the hospital not knowing what the community was facing. When he arrived at the emergency department, it was a scene like no other, he said. By the end of the event, Sunrise Hospital had seen 214 patients, plus another 30 that were treated and released before they could even be registered, and performed more than 83 surgeries within the first day. Of the patients who arrived, 92 had no identification, having lost their purses and wallets as they fled the fusillade of bullets.
Sklamberg explained that the hospital treated 124 gunshot victims, more than half of whom were brought to the hospital in private vehicles that had followed ambulances to the hospital or used mapping programs. One lesson learned from this experience was that it would be good to have a system that could direct those using cell phones to the proper hospital using geolocation. He recalled that his hospital received a call from one of the community hospitals who had a patient who had been shot in the head and needed a neurosurgeon. Unfortunately, there was no way to bring that patient to Sunrise Hospital in time.
At Sunrise, 16 deaths occurred. Ten were dead on arrival, four were beyond saving when they arrived, one was brain dead and had care withdrawn, and one died on the operating table. The hospital did not run out of blood thanks to receiving blood redirected from the non-trauma centers. At the time of the shooting, Sunrise’s emergency department was already full, as were all 700 beds in the hospital, but by 6 AM, the hospital had
discharged 180 patients. By 11 AM, emergency department operations had returned to normal.
As Sklamberg had mentioned, 92 patients came in without identification, and at one point more than 300 family members were in the hospital’s auditorium looking for their loved ones. “We went through this the old-fashioned way,” he said. “We sent staff up to the floors and took descriptions of the patients, had the family members give us descriptions, and sat in our board room and matched them.” The two major identifiers, he noted, were tattoos and piercings. He added that the hospital was fortunate in that the VA and HCA both provided resources immediately. Within 24 hours, there were two VA mobile vans and grief counselors who could help both patients and staff members. Of the 3,000 Sunrise staff members, about 1,100 sought grief counseling and support, said Sklamberg.
Because the Las Vegas Strip is so close to the hospital, staff at the hospital have some experience dealing with surge capacity. It is not uncommon on New Year’s Eve and New Year’s Day for the emergency department to see more than 700 patients. The hospital’s trauma surgeon and emergency medicine physician who were on duty at the time quickly decided how to set up a triage process that was able to parse patients into different areas of the hospital by the type and severity of their wounds. This enabled the specialists, as they arrived, to go directly to the appropriate area and triage their patients within the confines of one area, which reduced confusion and helped increase throughput to a degree that the hospital was able to continue accepting patients throughout the ordeal. One issue that arose was that the hospital ran out of mass casualty tags, so the trauma teams resorted to the old-fashioned procedure of writing vital signs on patients’ foreheads with Sharpies.
An Ambulance Service Perspective
Forty-six years ago, with a degree in communications engineering, Richard Zuschlag founded Acadian Ambulance Service. Starting with two ambulances and eight medics who were Vietnam War veterans—before the era of licensed paramedics and emergency medical technicians—Acadian, the largest employee-owned ambulance service in the nation, now serves Louisiana, Mississippi, and Texas with 55 ambulances and 15 aircraft, and transports nearly 700,000 patients per year. Since 1971, Acadian has gone through almost 100 hurricanes and thousands of mass casualty vehicle incidents, train derailments, chemical plant incidents, and mass shootings.
From his perspective, the federal and state government responses to Hurricane Harvey had improved greatly since Hurricane Katrina. Zuschlag attributed that improvement to increased training, to the federal government getting everyone on the same page, and to the establishment of
regional trauma-based emergency centers in Texas. During Hurricane Katrina, he said, many things went wrong, and both the governor of Louisiana and the President made mistakes. One reason for the difficulties encountered during Hurricane Katrina was the total failure of all forms of communication, including the entire wireless telephone system, the state police communication system, and the sheriff’s communication system. In Louisiana, 18 parish 911 centers went dark when the storm came through, but because there was a statewide 911 call center, emergency services were able to continue to be dispatched. Nonetheless, miscommunication at all levels seemed to be the norm.
Given the challenges of finding safe routes into New Orleans in the aftermath of the storm, Zuschlag hired 30 petroleum helicopters out of Lafayette, Louisiana, to fly staff back and forth into New Orleans to help evacuate the hospitals there. At one hospital, his staff and the building engineer used flashlights to create a landing zone so the helicopters could land and evacuate critically ill infants. All told, his team was able to evacuate 80 babies from three major hospitals and take them to Baton Rouge.
Zuschlag recalled that when Laura Bush visited the communications center, he wrote a note to her husband, the President, explaining that no matter what was going on between him and the governor, the first disaster was the storm, the second was the levees being breached, and the third was the damage to the region’s health care infrastructure and the need to evacuate not only hundreds of patients from seven hospitals, but hundreds of relatives who had come to the hospital, along with 85 dogs and cats. That note evidently got the president’s attention for his chief of staff called at midnight, and Zuschlag was able to explain the situation, which was that the Louisiana National Guard, which normally would have provided help, was deployed to Iraq, leaving what he called the second and third string behind. “All of their barracks were flooded, and they did not have any vehicles, ammunition, guns, or radios,” said Zuschlag. Hurricane Katrina struck on a Monday morning, and it was not until Friday that the U.S. Army arrived with satellite phones and support personnel that the hospitals were able to be evacuated.
Though everybody tried to do the right thing during Hurricane Katrina, the bottom line, said Zuschlag, was that too many things happened in the wrong way, largely because of a lack of communications capability. His concern going forward, with so much of the communication infrastructure moving to the Internet, is that a hacker could take down a big piece of the region’s emergency communication systems. He credited FEMA’s National Emergency Management Information System with doing a good job with training and developing protocols that have aligned public safety agencies, volunteer organizations, and public and private health care systems for disaster response. He was impressed during Hurricane Irma in 2017 with
the way FEMA worked with American Medical Response (AMR) to enable companies such as his to ensure that paramedics are properly credentialed to work across state lines.
One thing Zuschlag has done in the years since Hurricane Katrina is work on interoperability of communication systems. He has also worked with the Louisiana Emergency Response Network to establish a system whereby every ambulance company in the state that is transporting a trauma patient can call the network’s operations center to find out which hospital would provide the best care for a particular patient. In Texas, the regional advisory councils have done an excellent job organizing the response to mass casualty events and disasters, and their involvement during Hurricane Harvey was an immense help. One challenge that did arise was finding the right kind of watercraft to rescue patients. He noted that Texas and Louisiana are now working to properly credential members of the Cajun Navy, a volunteer organization that played a crucial role in rescue operations.
One thing Zuschlag noted was that every disaster is unique, and something always occurs that nobody had ever thought about before. One recommendation he made based on his experience with Hurricane Harvey was that the federal government could do a better job of having assets such as food and water, temporary shelters, security, and sanitation available for first responders. Other recommendations were to improve the mental health capabilities of the 911 system—mental health has become a bigger issue than most people realize, he said—and to develop a better system for organizing the Cajun Navy so they can use the Internet to register their boats and get apps on their phones so they can communicate with regional response centers.
DISCUSSION
Starting the discussion, Ricardo Martinez asked the panelists for the one thing they would do that would make the biggest difference in improving the response to a disaster. Cormier said he would institute better training programs at the coalition level to help with critical thinking skills for making decisions during a disaster. DeSalvo said she would boost funding for public health because it could be a huge first responder asset given its authority over safety, sanitation, air quality, and other important environmental challenges that arise following a disaster. “If we could have a mandatory funding stream for state and local public health, they would have more strength to not only surge, but be able to maintain partnerships and other work every day,” said DeSalvo.
From his experience during Hurricane Harvey, Erb said she would work ahead of time to identify triggers that would be used to evacuate a
health system before the situation becomes dire. Sklamberg’s suggestion was to standardize cell phone power cords. His hospital now has power cords as part of its emergency stores of water and other supplies, but the multitude of connections means he must have a multitude of cords in stock. Zuschlag said he would require hospitals and nursing homes to have a comprehensive evacuation plan as a licensing requirement. In his experience, current evacuation plans call for moving patients locally, with no second or third choice if the disaster takes out those local facilities, too. As a result, there is often a great deal of confusion and delay in evacuating patients in regional-scale disasters.
John Hick asked Erb and DeSalvo to talk about the role of health care coalitions during the recovery phase and the opportunities for coalitions to engage in community planning for the recovery stage. Erb said that from the Gulf Coast perspective, HCA could have been better coordinated with the coalitions to understand what she and her team would be looking at after the storm and what the plan was for setting up makeshift triage tents, for example, in the emergency department parking lot or for serving dialysis patients who cannot get to their usual dialysis center. Although she and her team were able to work through these issues with CMOC, the real opportunity would have been to have those discussions before the storm hit.
Before answering Hick’s question, DeSalvo raised an issue that arose during Hurricane Katrina regarding nursing home evacuation. It turned out that multiple nursing homes had contracted with the same ambulance company for evacuation capability, and when all the nursing homes requested evacuation simultaneously, the capacity to fulfill all the requests did not exist. Returning to the question at hand on coalitions, New Orleans did not have a formal coalition and depended instead on the health commissioner convening the community and having a good relationship with hospital leadership and emergency preparedness. These existing relationships mattered both during the storm and afterward in that they helped get the community health centers and ambulatory clinics involved to deflect surge visits to the emergency departments. Where this informal, human capital approach has not worked well was in dealing with people who are not in the hospitals or nursing facilities yet still receive care in their high-rise subsidized housing, so there needs to be better coordination with the home health agencies and other social services that have relationships with these individuals.
Having given up on the idea that electronic health record interoperability would ever happen, Arthur Kellerman of USUHS said his one wish was that every electronic health record vendor would at least populate a minimum essential database of 30 to 40 datapoints that every clinician could access in an emergency, then leave a record of their access to those data. To incentivize that, he would have Medicare, Medicaid, and private
insurance companies require that every electronic health record has that feature in order be paid for medical services. DeSalvo agreed with his idea and said that eligibility to be a Medicare provider is an incentivizing mechanism that has not been leveraged regarding interoperability at this level. She also thought that Medicaid and commercial claims data could be used to identify the most vulnerable people and know where to send the ambulance or boat to get them.
Kellerman then asked the panelists, given their experience, what ASPR, HHS, and other federal agencies could do that would help their communities and regions to be better prepared for future events. Zuschlag’s suggestion, which was less about preparedness and more about saving the federal government a great deal of money, was to let ambulance services use less expensive vehicles to transport people to walk-in clinics. In his area, for example, 30 percent of the 911 calls result in someone being transported to a walk-in clinic rather than the emergency department. Using a vehicle other than a fully equipped ambulance would be less expensive and produce a faster turnaround. Kellerman wondered if some of those patients could be treated at the scene, and Zuschlag said he would like to try a demonstration project in collaboration with a hospital to do just that.
Sklamberg noted that there are many efforts in Clark County and the rest of Nevada to better coordinate care and resources at the time of a disaster. What would help would be a system to provide real-time data from the scene and area hospitals, as well as a means of identifying patients, either through fingerprints or retinal scan. During the Las Vegas shooting incident, it took 6 hours to identify many of the patients brought to Sunrise Hospital, and none of the individuals who died had identification, making family notification difficult.
Erb noted that every HCA facility in Houston wanted armed guards to help deal with possible situations that might develop with the surge of patients and family members. HCA found itself in a fight with oil and gas companies to line up security services. “Next time, I would beat oil and gas to the punch,” she said.
Ira Nemeth from the American College of Emergency Physicians and the University of Massachusetts Memorial Medical Center asked the panelist to comment on whether communication channels need to be formalized and structured or if a human capital, muscle memory, know-who-to-call approach is a sufficient or even better approach to maintaining communication during a disaster. Cormier replied with a story. During Hurricane Katrina, someone from New Orleans Charity Hospital called the emergency operations center requesting evacuation for its patients when the facility started flooding and losing power. Charity Hospital was told to move its patients to lower floors and be ready to be evacuated. Around the same time, the head of HCA’s local division called a friend at the emergency operations
center and was told that the situation was a mess and that HCA was on its own. HCA leadership decided to take charge of evacuating its Tulane Medical Center, while Charity Hospital struggled to evacuate its patients. “When you speak about formal communication, that formal communication has to be as honest as that muscle memory communication, and that is why we participate in national calls and regional calls, so we can listen and share information,” said Cormier. “But until we can get the same type of information that we are getting from those one-on-one calls, I think we are going to struggle.”
Zuschlag told another story in response to Nemeth’s question. During Hurricane Katrina, one of his paramedics who was on one of his helicopters reported that five Blackhawk Helicopters were sitting on the ground at the Baton Rouge Airport and had not moved during the disaster. Zuschlag called his local manager and told him to contact the commander, which took some doing, but eventually he got on the phone. Zuschlag told him that the general in charge of the military response had put Zuschlag in charge of getting as many helicopters as possible down to New Orleans. Those five Blackhawks spent the next 3 days in New Orleans evacuating the sickest people out of the Superdome. Martinez added that social media, another form of informal communication, has become an important means for finding places for patients during emergencies.
An unidentified participant asked the panelists for any lessons they learned regarding security matters during a disaster. DeSalvo replied that one thing DoD brings to disaster response is that it does not have an agenda in the community and so it is not trying to vie for territory and be in charge, which she said is one of the ugly parts of disaster response. During Hurricane Katrina, the military’s agenda was to do whatever was needed in terms of providing security and helping in whatever way it was needed. In her opinion, during a disaster when local government is overwhelmed, more consideration should be given to leveraging military assets because the military can come in and solve problems without trying to be the shiniest organization in the local community.
Michael Consuelos from The Hospital & Healthsystem Association of Pennsylvania asked DeSalvo for ideas on how he can get his emergency preparedness team to meet with his population team and talk about preparedness for future disasters and build more resilient communities. DeSalvo replied that Bloomberg Philanthropies has been funding work on how to build communities that are both climate resilient and socially resilient. This work has produced papers in the literature that can guide communities and health care systems. She also noted that there is an enormous amount of information that can guide the health care system and public health in efforts to build up resource-poor communities and individuals. Many private payers and Medicare are trying to understand how to use that information,
and there are some “ready for primetime approaches” that are emerging to identify who is most at risk. For her, hospitals and health care systems should have an obligation to be part of the Medical Reserve Corps and volunteer to work with the local health department to go door to door and reach those outside of their walls during a disaster.
DeSalvo also expressed support and appreciation for the Public Health Service Commissioned Corps, which she said the nation underuses when running training exercises in the field. Martinez added that the public is another underused resource with regard to responders. He noted that when the Brussels bombing occurred in 2016, 100 civilians who had been trained by the European Red Cross went to the airport to help provide care for the considerable number of casualties. “We have an issue in this country where we rely on calling 911, which will always be overwhelmed in a disaster, so this is something we may want to look at as we go forward,” said Martinez.
Ronald Stewart from the University of Texas Health in San Antonio remarked that there is no doubt that public health needs help and that public health will play a key role in the preparation and recovery phases. Unlike DeSalvo, he believes the first responders and acute care segment of the health system will be going into the community and bringing those who need care into the hospital. Given that, he believes that federal and state governments need to include hospitals and EMS as part of the command system that is involved in making decisions during a disaster. On the acute care side of the equation, Stewart said that hospitals and health care systems, no matter how prepared they are, are not self-sufficient. “We should shoot for an interdependent, diverse health care system that works together as a team,” said Stewart. “Be as strong as possible but realize that on the scale of these events we’re talking about, we are not going to be self-sufficient.”
In Stewart’s opinion, it is dangerous for a health care organization to think it is self-sufficient. Cormier responded that when he talks about being self-sufficient, he does not mean isolated. “We share resources and work with the federal government,” said Cormier, and in his mind, being self-sufficient means that he has enough resources on hand so that government or other regional resources can be used at other sites.
Keeping with that theme, Sklamberg remarked that his institution could not have handled the Las Vegas shooting situation without assistance from the entire community, which meant sharing resources, sharing assets, and communicating where the best care for certain patients was. “If there had been discussion about doing this ourselves, we would not have survived,” said Sklamberg, who again stressed the need for real-time coordination when disaster occurs.
Zuschlag said he was overwhelmed when some 500 ambulances from across the nation showed up and wanted to help in the aftermath of
Hurricane Katrina. With all communication systems down, it was challenging to get them credentialed and into the disaster areas. “It is amazing when something that big happens how the American people come forward and want to help,” he said, and putting all of that help to work was definitely a team effort. He noted that although the number of deaths was tragic, the number of people saved is not discussed often.
Brendan Carr from ASPR asked if private-sector payers were part of the coordinating and planning effort. DeSalvo replied that payers did participate in the response during Hurricane Katrina. For example, the technology team from Blue Cross Blue Shield of Louisiana leaned in hard to create an electronic claims-based record for people in Louisiana to find information on the medications that people needed. That system, KatrinaHealth.org, was a significant piece of New Orleans’s recovery planning to create a more resilient health care system. Erb said that payers were contacting HCA’s service line vice presidents requesting information on where their patients were transferred, and she acknowledged that HCA did not do a great job of sharing that information in the moment as it was low on the priority list. HCA is looking at how to better handle those requests in the future.
Zuschlag said that during Hurricane Katrina, the Federal Aviation Administration (FAA) in Dallas called and asked his company to organize as many civilian helicopters as possible to help evacuate the hospitals. Though he responded immediately, 48 hours passed before he got authorization in writing so the company could be reimbursed eventually. He commented that the private health care community should not gouge the federal government, but unfortunately, many of his associates did. Perhaps because he was reasonable in the charges he submitted, FEMA and the FAA reimbursed him for services that went beyond the original contract, including flying food, guns, and ammunition to law enforcement and flying food to affected prisons. He noted, too, that FEMA and the State of Texas were far more organized during the 2017 hurricane season.
Mahshid Abir of the University of Michigan Medical School asked the panelists if they encountered any particular challenges during Hurricane Harvey in emergency care or inpatient care for pediatric patients. Martinez replied that his hospital had 30 children in his emergency department after a carbon monoxide event at a local school, pointing to the need to have the capabilities to treat multiple children during that kind of everyday emergency. In that case, his facility called on coalition members in the area to provide the necessary supplies and equipment. “A typical hospital does not have the expertise and the equipment to handle that kind of emergency,” said Martinez. Sklamberg said that during the Las Vegas mass shooting, his hospital’s pediatric subspecialists were helping care for adults, with one of its pediatric surgeons serving as a scrub nurse. “In times like that one, you use every resource you have,” he said.
Commenting on DeSalvo’s suggestion to use social determinants of health to identify those outside of the health care system’s walls who need care during a disaster, Konduri said there are many efforts across the country to do just that. The challenge he sees is having the capacity in public health and social services to provide the care those individuals will need during a disaster. Phyllis Frosst from Squirus noted that ASPR’s emPOWER initiative is working with Medicaid and all-payer records to look at the broader population in a community to identify who would be at risk during a disaster. One thing that has come from this work has been the good public- and private-sector engagement in the project, which can now produce lifesaving information in hours by leveraging Medicaid data.
DeSalvo commented that the nation is in the early days of developing financing models that support the clinical environment’s efforts to identify and link people to social services resources, with Medicaid programs in Massachusetts, Minnesota, New York State, Oregon, and Rhode Island leading these efforts. In Kansas City, a pediatric hospital has created a one-stop shop for social services, and the American Academy of Pediatrics has a toolkit for identifying people in need and linking them to resources. Frosst then asked the panel for suggestions on what kind of information could help with preparations to reach those in the community who might need care in advance of a massive storm. Cormier suggested a layered map that would show patients the type of equipment they are using and what resources are responding to them, which could help reduce duplicated efforts.
Eric Epley from STRAC remarked that he has been involved in the responses to Hurricanes Katrina, Rita, and others, and the federal government’s response to these disasters has improved greatly since Hurricane Katrina. He also supported the emPOWER project’s work. He then noted that the San Antonio area is using its regional trauma and emergency health care system to support cardiac, stroke, and perinatal care as a means of not having to build independent systems. The area’s newest effort is to use this infrastructure to help with mental health patients who have a history of needing help. This initiative is working with law enforcement to bring individuals straight to psychiatric hospitals, rather than to the emergency department, and using software to track social determinants of health and match patients with resources in the community. His question for the panelists was whether organizations dealing with social determinants of health, including EMS and acute care, should be involved in the health care coalitions.
Definitely, replied DeSalvo, who noted that San Diego and St. Louis, and probably others around the country, are taking a similar approach to San Antonio. She added that EMS and emergency departments often know much more about what is going on in someone’s home than a primary care physician does. From her experience, it should be possible to build an infor-
mation platform and navigation tools to identify who is going to bed hungry and who is dependent on electricity to power their medical equipment.
Gina Piazza from the Charlie Norwood VA Medical Center, the Medical College of Georgia of Augusta University, and the American College of Emergency Physicians’ High-Threat Task Force asked how Sklamberg’s hospital billed for the patients it treated and released without being registered or charted. Sklamberg said that Sunrise Hospital absorbed the cost of caring for those patients. In addition, the hospital has no plans to collect any co-pays or deductibles for a patient treated during that mass casualty event. That was not planned, he said, but it is a commitment that hospital leadership has made to the community.
To close the session, Kellerman recounted a story from the early days of Hurricane Katrina, when Admiral Thayer Cochran told the federal employees gathered in a warehouse in Baton Rouge who were struggling to coordinate the response to the storm that they should just worry about doing what is right, and to help the affected people as they would help their family and neighbors. If they had to break a rule to get something done, he would take the heat. Kellerman’s question to the panel was how important is it to just do the right thing and not worry what the lawyer or claims adjuster thinks later. “This is something I think all of us who work in emergency care struggle with from time to time, where you have a lawyer perched on your shoulder whispering, ‘Don’t do that, you might get sued,’ or ‘Don’t do that, you’ll never get paid.’” DeSalvo replied that her husband said to her every day in the weeks after Katrina that she should just do the right thing until she got fired. Zuschlag said that as an employee-owned business, his company’s attitude is that patient care and saving lives is job number one. “If the whole company went bankrupt because of it, so be it,” he said.
Sklamberg echoed those comments and said he and his colleagues did not question themselves at any time during the response Las Vegas mass shooting. “It was always about the patient,” he said, “and I am certain during the course of the event that there were HIPAA [Health Insurance Portability and Accountability Act] violations.” He added, though, that health care systems also have to be responsible to families during these types of disasters. “Part of being a leader is providing hope and information, and even if it was not definitive information, giving folks updates on a regular basis is important,” added Sklamberg.
Erb recalled how at one point during Hurricane Harvey, when multiple voices were arguing for different courses of action, the division president shut the door to the command center, muted the phone lines, and had a real discussion with the senior leadership team about needing to make decisions to do the right thing for its patients and for the health of the affected divisions. She noted that one big win for the leadership team was the decision to work with HCA’s strategic communications group to push out “mission
moments” that kept those in the field apprised of what was going on across the system.
Cormier said this is a struggle every day for clinicians in the emergency department who are scared to discharge a mental health patient or not prescribe an antibiotic. “But you see that drop during a disaster and you see competition drop in communities,” said Cormier. The challenge, he said, is that the “right thing is not always this big glowing answer on the wall. Many times, it is a gray thing behind a cloud and somebody has to make that decision.”
