In early March, a swath of deadly tornadoes plowed across the nation's Midwest and South, once again underscoring the importance of hospital disaster planning. The storms killed at least two dozen people while leveling a number of small towns. By March 5th, EDs from Nebraska to Georgia were already in review mode, discussing what aspects of their plans worked well and what needed to be revised. And the tornado season was just getting started.
Few areas were hit as hard as West Liberty, Ky., where an early evening twister marched right down the city's main corridor, knocking down power lines, ripping off roofs, and significantly damaging Morgan County Appalachian Regional Healthcare (ARH) Hospital, the small, critical access facility that serves the community. "When the tornado warning came out, it was actually for a different area," explains Gail Perry, CEN, the hospital's ED nurse manager. "What happened was the tornado took a right turn that forecasters were not expecting."
Perry, who was not at the hospital when the tornado struck, had to walk a long distance to make it to work because the roads were not passable with all the damage. When she arrived, it was immediately clear that staff were going to have to make some changes in their disaster plans because the ED had sustained damage from the tornado. "The staff barely had time to remove patients and get them into a safe hallway, but there were no injuries that occurred [from the damage to the ED]," says Perry.
All of the hospital's disaster plans relied on the ED being the central area in such an emergency, says Perry, but staff quickly shifted gears and transferred all the patients to a clinic area instead. "It was the only area we had," she says. All the windows were blown out of the ambulance entrance area as well, so any arriving ambulances had to bring patients to the ambulatory entrance, on the other side of the hospital, she explains.
The ED only received 15-20 tornado victims, primarily because the heavy tornado damage in the West Liberty area limited access to the facility. "We did initial triage, stabilization, and treatment, but then we had to evacuate the hospital," says Perry.
One of the biggest challenges in carrying out the evacuation involved communications. The hospital had no direct communications with its regional referral center, St. Claire Regional Medical Center in Morehead, KY. Consequently, the staff at Morgan County ARH Hospital got creative, using a fax machine to copy charts and send them along with the patients. "Our ambulance personnel were in contact with St. Claire Regional, so we provided them with as much information as we could," says Perry, stating that the ED director at St. Claire later noted that one of the patients transferred to his facility actually arrived with a report written on a paper towel.
Morgan County ARH Hospital went for several days without an operational lab or radiology department, but staff kept the ED open for absolute emergencies, says Perry. "The only kind of communication we had within the hospital itself was walkie-talkies," she says. "You become dependent on all the technology, and it is really hard to imagine what happens if you have none of it. This doesn't just leave you without the technology, it leaves with you without vital information that you are used to having."
With the hindsight of having gone through this crisis, Perry advises colleagues to consider all of the possibilities when devising and practicing disaster plans. "You have to have a backup plan," she stresses, noting that her hospital staff found themselves having to deal with an internal disaster and an external disaster simultaneously. "You assume when you have an internal disaster that you will have assistance from county officials, EMS, and those types of resources. But in our situation, they had their hands full too." (Also, see "Take advantage of smaller-scale crises to work your disaster plan," below.)
Plan for the worst
While forecasters could not precisely pinpoint the path of the tornado in West Liberty, there is no question that improvements in weather forecasting have gone a long way toward helping to insure that hospitals are in a position to anticipate the potential for this type of disaster. It made a big difference to hospitals in southern Indiana, another area hit hard by the storms.
"I was in touch with our local EMA agency, and throughout the day [March 2] I was alerting all of our administrators about the possibility that a large-scale tornado could happen," explains Derek Rainbolt, the safety director at Margaret Mary Community Hospital (MMCH) in Batesville, IN. "We prepped our evaluation equipment and medical equipment in case of an influx of patients, and kept a significant number of staff here."
Rainbolt was also in touch with other hospitals in the region to share ideas regarding preparations, staffing, transport units, and other critical issues. "We bounced ideas off of each other the whole day," says Rainbolt. "Communication was key."
In the end, the hospital only received six patients over a three-hour time period as a result of the tornado emergency, so the hospital was overly prepared, but Rainbolt stresses that it could have been a lot worse. "You really need to plan for the worst. It does you no good to plan for a small-scale event. Plan for the worst, and that way when you handle a smaller scale event like we did, you can handle it and manage it pretty efficiently," he says.
It is critical that hospital administrators keep in mind that a natural disaster can happen to anybody, adds Rainbolt. "You need to take this seriously and try to plan for it," he says. You want to make sure you have the proper plans in place, your staff have been trained, and you have held some drills."
Then, after an event like this has happened, it is important to analyze what worked well and what could have been better. For instance, at MMCH, there was some minor confusion during the tornado crisis about who was responsible for specific tasks, such as registration and managing the communications line, so Rainbolt is now working with colleagues to update the system and eliminate those issues. He is also in the process of revamping the hospital's emergency operations plan to include more ED staff.
"With disaster planning, you need to focus on the area that is going to get hit first, which is going to be the ED 100% of the time, so we really have to start and end there," he says. "It is their department and they know where everything is," he says. "It just helps with team building to enable them to have a say in the planning process because they're the ones who are going to have to deal with the influx of patients."
Consider non-medical resource needs
As a level 1 trauma center, the University of Louisville Hospital (ULH) began preparing for an influx of patients as soon as it received notification that tornadoes were headed toward the region, explains Barbara Dimercurio, RN, MBA, the director of Emergency Services at ULH. "We received calls from outlying facilities asking us how many patients we could manage, and we told them we would take as many patients as they needed to send us," she says.
Then it was a matter of allocating resources. "We had to decide who was going to stay over [from the day shift], who was going to come in, and who was going to operate the ED from a capacity management standpoint," she says. "We had to notify our attending [physicians], and allocate additional physicians to the ED."
In addition, the trauma team was alerted to contact additional staff members and to be prepared for a large influx of patients. "We notified house staff to make sure everyone realized that we needed to get patients in and out of the hospital who could move so that we could allocate beds for tornado victims that would be coming our way," says Dimercurio. "We were under a tornado warning, so 'operation dark cloud' was called, which is the policy we follow in the hospital," she says. "We were unaware of whether the tornado would hit us or not, and we also had an external disaster going on in Indiana."
Since the ED waiting room is full of windows, family members either stayed with their loved ones in the main ED or they were routed to the basement, at least until the tornado warning in the Louisville area ended.
At the time of the tornado emergency, the ED was already operating at full capacity. The main ED only has 29 beds, and yet it averages about 40 patients in that portion of the department by mid-afternoon every day, says Dimercurio. "At one point [during the tornado emergency], we had 90 patients in our ED. They weren't all tornado victims, but we saw 25 tornado-related cases, and we admitted 19 of those," she says. "Every trauma patient [from southern Indiana] was flown here. We had patients that arrived who were amputees, and patients with other substantial injuries — primarily orthopedic injuries."
Staff were able to accommodate the high volume by making use of side hallways and ED entrance areas, and by putting some patients in chairs or recliners. "We used our triage area and our urgent care side, and we decided to put a physician out in triage to help facilitate decisions about which patients would go over to the fast track area and which ones would go to the main ED," observes Dimercurio.
The ED received help from other units in the hospital that sent down staff to assist with patient transport and other tasks. "We had people going to the blood bank to get coolers of blood to take to our trauma room, and we had additional housekeeping, food service, and chaplain services," says Dimercurio. "We expected to receive as many as 100 patients. We didn't, but we were prepared."
In addition, the hospital had plans in place in case the tornado emergency lasted for a longer period of time. "We did not release our day staff until 11 o'clock at night, our night shift staff came in early, and then we began to allocate resources for the next day," recalls Dimercurio. "We were unaware of how long this would actually go on, so we had teams that were prepared to come in at set hours to handle the next wave of patients."
While every crisis has unique characteristics, Dimercurio stresses that regular practice drills make a huge difference in ensuring that staff understand their roles. "You practice, practice, and practice, and make sure everybody is aware of what is going to occur, who is going to run the show, and who is going to be the task driver," she says. "Our staff said it was 'organized chaos,' but I think they ran with it."
Nonetheless, there were some wrinkles in the process that Dimercurio would like to iron out before the next crisis occurs. For instance, she says the hospital underestimated the number of people who would be calling to either locate family members or inquire about their conditions. And because the crisis occurred on a Friday, many of these inquiries came over the weekend when there were fewer people available to run down this information and provide adequate support services.
"From a nursing standpoint, we had it all covered, but things like chaplain services, additional food service and housekeeping staff — those were things that we did not properly account for [as the emergency stretched into Saturday]," she says. "This is something we can improve on in the future. The Red Cross and the Salvation Army need to be available, and just overall, there needs to be a communications plan for the weekend."