Natural disaster reaction averts a Houston disaster
25 feet of water showed what one hospital is made of
Memorial Hermann Hospital in Houston had some 540 patients in its 650-bed facility on June 9. Each of its 150 critical care beds were filled. Much of the city had heaved a sigh of relief when Tropical Storm Allison had passed away into the Gulf of Mexico. Then it doubled back.
Shortly after midnight, the hospital had water in the basement, which housed lab and pharmacy services, among others. "Over two hours it got so forceful it blew the hinges off of steel doors," says Juanita Romans, vice president and chief operating officer.
By 2:30 a.m., the lights were out. And not just the main lights, but the backup generators, too. "There was no light. Ventilators, IV pumps, running water, even our toilets were down. We had no monitors working."
As a level-one trauma center, Romans says the hospital is prepared to handle external emergencies. But over the next 30 hours the hospital, its staff, and its patients would be sorely tested. The experience, while frightening and grueling, would show Memorial Hermann at its best. Indeed, the Joint Commission on Accreditation of Healthcare Organizations features the facility and its reaction to a natural disaster in the Lessons Learned section of a special emergency preparedness issue of its newsletter. (For more on the special issue, see "JCAHO responds to Sept. 11 tragedy," in this issue.)
The first order of business was taking care of patients who needed respiratory assistance. "We had residents, respiratory therapists, and even secretaries hand bagging patients," says Romans. "We monitored drips the old-fashioned way. We used flashlights."
Streets were flooded and impassible, so the CEO was flown in by helicopter. Romans walked into the facility after driving as near as the flooded streets would allow. Contractors were immediately called in to estimate the damage, and light sources, batteries, and flashlights were flown in during the wee hours of the morning. By 8 a.m., a command center was set up.
Several teams were created. The medical triage team was headed up by the on-call trauma surgeon who happened to be the director of critical care. "She walked from floor to floor to triage patients to determine who had to be transferred first." By about 8:30 a.m., when it was apparent the electricity wouldn’t be up quickly, it was that physician who made the call to start transferring patients.
A courier team was created to ferry messages and supplies from floor to floor, and once adequate telephone service was created — partly through the use of cell phones — the staff began the arduous task of finding beds for patients. As the day progressed, Romans says that experts told her the electricity would be down for days, forcing the CEO to call for the complete evacuation of the hospital.
It was clear the facility would be closed for some time. There was 34 feet of water in the sub basement, and in an atrium that connects some of the buildings on the 2 million square foot campus, there was 25 feet of water — complete with a grand piano floating in the midst of it.
It was like an elaborate dance’
Romans says that once the streets were cleared, both air and ground were used for patient transfers. "The command center was used as a warehouse of information about where patients were and where they were going," she explains. "A medical transfer team for both pediatric and adult patients determined who had to go first by level of acuity. A dispatch team was stationed at the emergency room calling for patients, who were carried down dark flights of stairs on backboards with flashlights."
Each patient came with his or her chart and a sheet of stickers that were used to identify where they were going. The stickers were placed on a board in the command center, as well as on the patient.
Three Hermann-owned helicopters and several National Guard Blackhawk helicopters used a blocked off street as a landing pad. "It was like a valet service for helicopters," she notes. "It was like an elaborate dance." Four ambulances were backed up into the bay at once, loaded with patients, equipment, and nursing staff, and then dispatched. Then another four were called in.
For 30 hours, this went on, says Romans. Not a single person was hurt — either staff or patient. Not a single patient died. There were no significant complications among patients. The worst that happened was one woman got stuck in an elevator for a few hours. She was shaken up, but not hurt, Romans says.
"Everyone did whatever they had to do without complaints or questions," notes Romans. "There was a real esprit de corps." Local residents and area Boy Scout troops — even patients’ families — pitched in acting as runners to bring bottled water up the stairs to staff.
It took a week to get temporary electricity back on, but it wasn’t enough power to turn on the air conditioners in the middle of a Texas summer. It took a week to pump the water out of the basement. And as a result, the hospital was down for 37 days.
Winging it, in a way
"If you ask whether what we did was written down in some book, it wasn’t," admits Romans. "But we have disaster drills on a routine basis. All we did was take our disaster plan and put it in reverse. Rather than triaging patients coming in, we were triaging them to go out. We still created our command center and triage team. The only unanticipated thing was that we needed an internal transport system."
The best measurement the hospital has of its success was that outcomes were positive. There are other, more subjective measurements that the facility is starting to take, too, that look more at how people feel about the incident. Press Ganey conducted a satisfaction survey of all the patients and families that were in the hospital at the time. There were no special questions on the form about the flood — just the standard survey. While there were some who weren’t happy with how the hospital did, overall, the scores were excellent, says Romans.
Morale is the best measure of staff feelings, and the hospital leadership did what it could to keep morale high during a difficult period. "We tried to keep our staff in mind by sending them to different hospitals [within the Memorial system] to work so they would still have a paycheck," Romans says. After the event, daily meetings were called to let staff talk about their feelings. "We call them heroes and even had a heroes’ dinner."
How the hospital performed when under the gun was also discussed through focus groups and at manager meetings. And while Romans says with conviction that the hospital should get an "A" for its performance, there were still some lessons learned. First and foremost: Only put services that aren’t critical to patient care in the basement, says Romans.
It’s probably not a good idea in flood zones to keep backup electrical systems there, either. Generators that used to be kept in the basement at Memorial Hermann have been moved to the first and fourth floors. Extended life batteries for flashlights and IV infusers have been purchased. The hospital had some red, external line phones that weren’t connected to the electrical system. But many of these had been unplugged and moved to other locations, rendering them useless when the electricity went down. Now they are all kept attached to those external lines. The hospital recognized a need for fully charged hand-held radios and oxygen powered aspirators, ventilators, and suction machines.
One key element to patient safety that Memorial Hermann has is machines that distribute medications on the units. But the keys to those machines weren’t on the floor. When the electricity failed, the machines went into lock-down mode. Staff had to send couriers to look for the keys and unlock all the machines. For a couple of hours, certain medications weren’t available.
Typically, when Memorial Hermann sends patients out of the hospital, their charts don’t go with them. "The way you identify patients now is they have these cards and you run it through an identifier. But it’s all electric. Without electricity, you don’t know who is in the house." Romans recommends that census reports be run hourly in busy hospitals. What saved her facility from losing anyone was the impromptu sticker system. "The label told how they were moving and their destination. One sticker was taken and put on a board, one went with them."
Another lesson learned the hard way was that managers should each have a copy of the emergency phone list and disaster manual both at home and at the office. "If you’re on call but at home, what’s the use of a disaster manual that’s at work?" she asks.
Lastly, Romans says having a single point of contact for the media frees up other managers and hospital leadership for more important tasks. "Use your marketing and communications personnel," she recommends. "We used the radio, television, and newspapers to communicate with our patients’ families and our staff. Having one person in charge helps you control the message while still providing information to the media. They’re hungry for the story, and if you don’t feed them, they’ll come looking for information when your time could be better directed elsewhere."
Romans knows her facility did well, but she doesn’t feel invincible. "Mother Nature can be really wicked," she says. "If we weren’t part of a strong system, if we weren’t a level one trauma center, I don’t think we would have done as well."
Watching hospitals in New York and Washington, DC, go through the horrors of Sept. 11 and its aftermath brings another thought to mind too. "There is a huge emotional component to disaster. At the start, you are strong, you are running on adrenaline. But the aftermath is hard. And while I think we feel very positive about the outcome of our disaster, I don’t think New York and Washington, DC, feel the same way."
[For more information, contact:
- Juanita Romans, Vice President, Chief Operating Officer, Memorial Hermann Hospital, 6411 Fannin St., Houston, TX 77030. Telephone: (713) 704-6614.]
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