Preparing for the Worst

Tornadoes. Extreme heat. Hurricanes. In the face of climate change, resilient hospitals must plan for the unpredictable.

By Robert Bittner on August 28, 2017

On May 22, 2011, Denise Dugan, then patient safety officer for St. John’s Regional Medical Center in Joplin, Missouri, was at home when the first tornado siren went off.

“I knew that we were under tornado warnings, and I knew it was going to be bad,” she said. “When the first siren went off, I took my dogs into the bathroom and waited. A second siren went off, and immediately everything went dead. After a bit, I heard the freight train noise people talk about. I’d been in several tornadoes before, but that was the first time I’d heard the noise. After a while, the TV came back on. I went outside, and nothing in my yard was touched. I live on 15th Street, and the tornado went down 20th.

“I took off to check on my mom and to go to the hospital. I got down to the corner, and it was packed with cars. I had to go down alleys due to trees in the street to get to my mom’s house. Other houses around hers had damage, but her house didn’t. The hospital was hit, so I headed there. I knew I wouldn’t be able to get close with my car because of the traffic, so I parked and started walking. Once I got [there], the police stopped me and said there was a gas leak. I heard that the hospital had opened a triage center in Memorial Hall. I met up with some others, and we popped in a car and drove there. We worked in the triage center all night.”

In the end, the EF-5 tornado — the most damaging category of tornado, with wind speeds of more than 200 miles per hour — killed 161 people and left a trail of devastation. Five patients and one visitor were killed at the hospital. But it could have been even worse.

“The hospital was moved 4 inches off its foundation,” Dugan recalled. “It was totally trashed. The windows were all broken. All the heavy doors on patient rooms were off, and some were split in half. IV poles had gone down the halls like javelins. Sewers popped from the pressure, so we had all the sewage coming out. We had 185 patients there. They evacuated within 90 minutes after the tornado struck.

“We had a plan, we drilled, and we prepared,” Dugan added. “And it’s a good thing we did. But this tornado was so strong, it just took everything we had.”

This was not an isolated incident. Joplin is in the part of the Midwest known as Tornado Alley. “We’ve had something like 59 EF-4s and EF-5s,” Dugan said.

Even so, a facility does not have to sit in Tornado Alley to benefit from storm-hardening practices and a focus on resilience.

“Every single health facility needs to pay attention to resiliency,” advised Angie Woo, who oversees climate resilience and adaptation at Fraser Health in Vancouver, British Columbia. Woo’s interviews and research among health facilities throughout North America — she helped organize a summit on climate change and resilience in 2016 — have convinced her that extreme weather events are not limited to tornadoes and hurricanes. And they are not limited by geography.

“Here in the Pacific Northwest,” Woo said, “we noticed unusual events that have caused strain on our hospital operations — for example, an extreme heat event in 2009.”

That event alone led to 120 deaths and taxed hospital staff and systems, such as cooling and ventilation.

“We [also] had an extreme wind event in our valley in 2015 that knocked out power to several hospitals at once,” she added. “They all had to go on emergency backup power at the same time, which had never happened before.”

As the effects of climate change become more common and more severe, Woo believes the warranted response is to create a culture of resilience that begins with hospitals and then extends to the community at large. Unfortunately, it often takes an extreme event before resilience becomes an investment-worthy priority.

Hard Lessons

On Oct. 29, 2012, Hurricane Sandy struck New York City.

“Sandy created a significant storm-surge hazard,” said Kelly McKinney, senior director of emergency management and enterprise resilience at NYU Langone Medical Center. “What ‘storm surge’ means is that a storm basically takes the coastline and moves it inland.”

One result was water infiltration at NYU Langone, which filled up basements and underground passages connecting a number of the facility’s buildings.

In its wake, the hurricane left behind millions of gallons of contaminated water, knocking out utilities and destroying equipment. “Power went out in the neighborhood, then some of our emergency power failed,” McKinney said. “At that point, the hospital was evacuated and closed.”

“We got the campus up and running 59 days after Sandy occurred,” added Jenna Agins, NYU Langone’s energy and sustainability specialist. Since then, “we’ve done a lot of work … to harden our campus overall.”

That includes flood-mitigation measures such as floodgates and doors, as well as relocating critical infrastructure to higher locations. These and other measures have earned NYU Langone a “Hub of Resilience” designation from the Disaster Recovery Institute International, a nonprofit that promotes disaster risk reduction.

“From a sustainability standpoint, we understand the implications of climate change on our community and the city of New York as a whole,” said Agins. “We see how climate change can impact extreme heat, extreme weather. In the coming decades, it’s very important for us to think about those things and do what we can to protect ourselves, our patients, and our employees, as well as our community.

“When FEMA releases its flood and storm projections, it’s important for hospitals to remember that [these projections] are often out-of-date and may not reflect changes in the climate that have already occurred,” she added. “FEMA publishes backward-looking projections that do not account for sea-level rise and more frequent, future extreme weather events due to climate change. This is why New York City and many other cities have focused on providing world-class, science-based modeling for flood and storm prediction that takes climate change and other changes into account.”

For NYU Langone, that means being prepared for a Hurricane Sandy-size storm surge, plus an additional 2 feet. “We’re currently undergoing transformation into a high-reliability organization,” Agins said. “We have a very strong team here that makes sure all the systems are ready leading up to an event.”

“Many of our mitigation measures aren’t in place day to day; they require 36 hours or greater to put into place,” McKinney added. “If we have a blizzard, we’ll implement emergency housing for staff. If there are mass-transit disruptions, we’ll put alternative transportation and housing in place to accommodate individuals. During an impending storm, the emergency-management team will bring together a system of individuals across the enterprise to manage to continue providing clinical care and education, despite any weather event.”

The situation is similar in Joplin at the rebuilt and renamed Mercy Hospital Joplin. “We kind of never stopped working to rebuild,” said Dugan. After the tornado struck, “we went from the triage center to opening a tent hospital within a week and were live with all of our electronic medical records.

“We moved into our current building in March 2015,” she said. “There are big cables built into the building, and they are buried deep underground, tethering us to the ground. A lot of buildings have roofs made of rubber panels topped with gravel. If a tornado takes that off, [the tornado is] in your hospital. Now we have a concrete roof. We have an energy plant built partially underground, connected to the hospital with a tunnel 25 feet underground. Our windows will withstand 150-mile-an-hour winds, and the windows in all intensive-care units will withstand 250-mile-an-hour winds. That makes it possible for critical-care patients to shelter in place.

“We monitor the weather all the time — three and four counties out,” Dugan added. “And we have warning apps on our phones.”

A Bigger Picture

Hardened structures and emergency procedures are essential. But Woo encourages hospitals to think about resilience as extending far beyond their own walls.

“There’s a tendency to focus on the hospital in isolation,” she warned. “Yet, critical infrastructure such as roads and electricity grids — which are ‘outside the fence’ — are essential to ensure reliable food and medical supplies. When we consider resiliency, we also need to think of the vulnerabilities in our global supply chain — for example, pharmaceuticals manufactured in other regions.

“A core aspect of resilience is self-sufficiency,” Woo added. “To achieve that, we need to build in redundancy and localize our supply chain and backups. The measures we take to build the climate resilience of a hospital — so it can operate as an island for three days, seven days, or more — will help ensure that it can withstand and bounce back from other disasters, including earthquakes.”

It is also vital to think of resilience in terms of the local community. In the case of extreme heat, for example, Woo pointed out, “It will affect the most vulnerable disproportionately: the elderly, the chronically ill, the very young. Those who are most vulnerable likely will be most reliant on public services, including health care, during and after a disaster. In this sense, their level of resilience is closely linked to health-system resilience.”

Woo acknowledges that sometimes there is a tendency for hospitals, and even hospital departments, to be siloed and isolated. “We need to work with public health, municipalities, and others with outreach programs to increase community resilience, which will help to increase self-reliance and self-care while reducing surge to the hospital during an extreme event,” she said.

“Resilience and sustainability — these are cross-sector and interdepartmental initiatives,” she continued. “We need not wait until we experience an extreme event to act. We need to keep in mind that our window of opportunity is not that wide. We’re breaking heat records year after year. The sooner we formulate a plan of action grounded in lived experience and robust data, the better we’ll be able to provide health services to patients in a changing climate.”