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June 16, 2020

Covid-19 is about to meet hurricane season. How can hospitals prepare for two disasters at once?

Daily Briefing

    Stephen Murphy, PhD, Assistant Professor of Public Health and Director of the Disaster Management Program at the Tulane University School of Public Health & Tropical Medicine, and the former Planning Section Chief of New Orleans Homeland Security & Emergency Preparedness following Hurricane Katrina, recently spoke with Advisory Board's Alice Thornton Bell, APRN, senior director, and Rebecca Soistmann, analyst, about managing disaster response during hurricane season amid Covid-19 and a potential second wave of cases in the fall.

    Q&As: How top health systems are tackling Covid-19

    Alice Thornton Bell: Thanks for taking the time to speak with us this afternoon. To start off, can you give us an overview of what hurricane planning looks like?

    Stephen Murphy: Of course! While there is a need to begin strengthening our local resilience and check building codes to reduce the need for mass evacuation strategies, we know that for the moment, we must plan thoroughly to protect life to the fullest extent possible. For hurricanes, obviously you must know your risk, when you would evacuate, how you would evacuate, and where you go. In New Orleans and Louisiana, our disaster management protocols involve tracking hurricane timelines and planning around those projections. We rely on a system we call "H-hour." In this timeline, H-0 (H minus zero) is the expected time when tropical storm winds strike the southern tip of our coastline. For a hurricane, we're looking at the five days prior to when H-0 is forecasted to happen. By at least H-96 or even H-120, which would be four or five days before the storm strikes the coastline, you need to activate mutual aid partners such as EMS (emergency medical services), other transportation and logistical assets and resources, and other responding agencies. If the storm is expected to be strong enough to force a mandatory evacuation (in New Orleans, mandatory evacuation is generally issued for a Category 3 or higher storm), we would activate logistical support early in the timeline in order to successfully operationalize the evacuation strategy as the timeline ticked down. In a mandatory evacuation, the city-assisted evacuation portion, which includes 17 pickup points across New Orleans to assist the projected 35,000 plus residents in need, would begin approximately at H-54 and run through H-30.

    During mandatory evacuations, H-30, which is more than a day before the storm strikes, is an important number across the state and especially New Orleans because that's when contraflow begins (highways only go one way: out). People go out and they can't come back in. Supplies can't come in beyond this time. Nursing home facilities need to have their EMS provider and other transportation contracts operational way before that, and those stakeholders need to be true to their agreed-upon timeline. Hospitals and long-term care facilities must know where the patients will go and must communicate the vulnerabilities and potential risks these patients might bring to receiving facilities, especially if it's Covid-19. Recognizing these elements will prove critical in all jurisdictions as planners dig deeper into the threat matrix and build out plans.

    Rebecca Soistmann: Based on your experience preparing for hurricanes and now with Covid-19, what do you think hospital leaders should prioritize to prepare for a potential second surge that could happen simultaneously with a hurricane?

    Murphy: Two key components jump out at me here. If they haven't yet, hospital leaders should be coordinating with other emergency response agencies in their area. A huge lesson that came out of Katrina was the need for a cross-jurisdictional, multi-stakeholder investment; not only financial, but also brain power and coordination in terms of how multiple agencies and hospitals came together to prepare for disasters. The integration of the public health preparedness system and the emergency management field cannot be understated—the events of 2005 forced the region to think differently than before and it led to tremendous multi-sector, systems-level integration. Breaking down those barriers upfront was essential to streamlining these integrated systems before an emergency takes place. Some of this is supported and initiated through the CDC's Hospital Preparedness Program's (HPP) Hospital and Healthcare Coalition concept, which has been gaining momentum since 2012. But work remains to be done along these lines.

    The second thing, particularly for hurricane response planning, is setting up shelters for vulnerable and/or electric-dependent populations during low-level storms not resulting in mandatory evacuation orders. For Covid-19, we had already established an alternative treatment facility (ATF) at the convention center—a facility New Orleans has used in past years as a responder task force site or possibly general population sheltering during low-level storms. But as Covid-19 cases increased, it became clear that the region needed substantial surge capacity to decompress hospitals and health systems in the area. The ATF in New Orleans has largely been serving as a recovery center to give hospitals the flexibility to receive more emergent Covid-19 cases. As patients come off mechanical ventilators, the hospitals re-triage patients and those no longer in need of immediate acute care are transported to the ATF. Thankfully, we are experiencing reduced Covid-19 patient loads, but the ATF remains a regional asset given the threat of increased cases alone but also in concert with the arrival of hurricane season.

    In the event of a hurricane, current operations could very likely be expanded as needed. Can ATFs in other cities be rapidly expanded to accommodate additional Covid-19 patients? Maybe the scope of practice at an ATF is modified to provide additional capacity or receive broader ranges of acuity of Covid-19 patients. Doing so might allow the hospitals to remain intact and operational, assuming an evacuation order is not issued, and other shelters can be stood up for general population members in need.  It's important for planners in other cities to explore locations where they can set up an easily modifiable, all-purpose center. I know a lot of planners thought that if we have a shelter-in-place strategy due to the storm, they could open one or two shelters for those who are electric-dependent or anyone whose homes were more at risk, based on community need. But now's the time that planners should consider doubling that number to maybe four community shelters, one so they have them available when the time arises, and two, to provide that physical distancing element needed for Covid-19. Earlier this year, you had a lot of vacant hotels and arguably it was a lot easier to shelter people while maintaining physical distancing. But now that most of the Gulf Coast has reopened, you really don't have those options in such an available capacity. Regardless, I think that emergency planners need to 'de-densify' congregate shelters open for evacuation as soon as possible

    Bell: It sounds like you're really thinking through both your hurricane response and how that intertwines with your Covid-19 response and the need to social distance. Would you recommend that responding agencies try to test evacuees at shelters for Covid-19?

    Murphy: Testing has been a sore spot for everyone, both antibody and viral testing—not enough, specificity and sensitivity concerns, turnaround time, etc. If you could possibly have some sort of test kit at shelters, that would be great, but it will still take time for the results to come back. As far as lab-confirmed, symptomatic patients, or others not yet confirmed, but exhibiting Covid-like symptoms, you don't want them next to air vents, potentially blowing aerosols and particles across the facility, and you do not want them near the air filtration if the filtration utilized at the facility is poor or substandard. Some of that common sense must come into the development strategy for what you're going to do. As we learn more about SARS-CoV-2 and Covid-19, we see more evidence suggesting filtration for smaller particulates is beneficial, which makes sense. Where you sit, for example, at restaurants, has shown to be important regarding transmission and exposure risk. There are even some hospitals entertaining contained UVC light "kill zones" within air movers, which are novel in that these are designed to be safe to operate with people in the room. Nevertheless, air exchange becomes critical and should not be overlooked in planning or in operations for Covid-19. A few environmental health scientists or industrial hygienists would be a great asset to consider for your planning teams in such an instance.

    Planners also should be considering several other questions, such as: How can you utilize a shelter in more than one way? Are there interior rooms that you can place the high-risk elderly couple alone, further from the general public? In addition, they should be focused on getting more PPE, temperature checks, doing the basics upon entry, having points of ingress and egress close enough to each other that someone can keep a constant eye on exits and entrances, but far enough apart so people don't cross paths. Those types of things are really important in community sheltering in this hurricane-Covid nightmare that we might face. 

    Bell: It's good to hear that there are plans in place to protect evacuees in shelters, but how do hospitals safely evacuate patients from hospitals in threatened areas, and does that change at all with Covid-19?

    Murphy: There's been a significant amount of conversation for years around the triage mechanism for the discharging of patients in advance of a storm. Many people in disaster management have adopted reverse triage, as in, you evacuate the more stable patients first because moving high-needs patients might disrupt their care and could do more damage than good and just maybe that storm alters course at the last minute allowing you to safely remain at that location with those critical patients. If you have a sheltering agreement with the state, or an existing relationship with other point-to-point hospitals, you should evacuate patients there early on. For Covid-19, maybe you keep those patients in the hospital if they require constant mechanical ventilation. But the key thing here is communication prior to the event: The clinicians at the receiving facilities need to know what conditions to prepare for, especially if it's Covid-19. 

    In New Orleans and Louisiana, we play in the same sandbox all the time, that's what we playfully call our integrated communication and operations. It's absolutely not a universal strategy for public health, emergency management, and the hospitals to be integrated like that already, but it's something we were forced to do in the situation coming out of Katrina. I would recommend that other systems consider integrating services in this way for disaster response as well. 

    Soistmann: You talked a lot about the ATF and hospital capacity, do you have any recommendations for how hospitals could prepare in-house?

    Murphy: Depending on your Covid-19 situation in the hospital, consider how you might protect suspected and confirmed cases and providers during evacuation. We saw this with Katrina, the receiving hospital really needs to know enough about the population they're receiving. If the receiving hospital's already at max capacity, they won't be able to take an influx of Covid-19 patients. Thankfully, we're seeing people come off ventilators more, and the global perspective seems to be that there are enough ventilators for the patients. If we see a second wave or peak in the middle of hurricane season, those numbers will change. You need to make sure hospitals have the resources to handle what you bring them. I'm not saying hospitals don't already do this, but it becomes even more critical with the threat of a natural disaster on the horizon. 

    Soistmann: One of the questions out there is how Covid-19 may impact volunteer capacity since many disaster response volunteers are typically older and therefore at an elevated risk for Covid-19. How can hospitals and other responding agencies prepare for this decrease in normal volunteer response?  

    Murphy: That's a really good question. It takes a lot of people, or "peoplepower," and force multipliers to successfully evacuate a city and its vulnerable as well as hospitalized residents. In New Orleans, we have had, a play on words of 'evacuation' and 'volunteer,' borne out of Hurricane Gustav in 2008 when we realized it would take a lot of peoplepower. It was created to own volunteer coordination for hurricane response for the city of New Orleans. It has become a separate, custom Emergency Support Function for the Emergency Operations Center, beyond the federal 1-15 functions already in place. With Covid-19, you have to be really careful. Even with a younger volunteer population, you have to worry about asymptomatic carriers. 

    There are also concerns about how to equip volunteers with needed PPE as those supply chains are stretched. A good strategy would be to find groups of people, through community emergency response teams, for example, that go through specific training. There are many certified teams across the U.S. and many medical reserve corps (MRCs) that have a younger volunteer base. Leverage that. Consider recruiting from graduate and undergraduate schools, and maybe younger professionals whose businesses aren't open or are recently unemployed due to Covid-19. In New Orleans, the MRC is taking a strong leadership role for hurricane evacuation in the midst of Covid-19 and ongoing efforts are being made to secure PPE for the volunteers. Easier said than done, but the efforts and progress are being made.

    Soistmann: You mentioned PPE. I'm curious, how are Tulane and other hospitals working to overcome the hurdles there given the potential need to also equip volunteers?

    Murphy: In general, for volunteers, different masks are a bit more available. Some grassroots efforts are creating cotton-based masks. But for health care providers the stockpiles really are limited by the supply chain.

    If this thing goes belly-up and we do have a huge hurricane during a second wave of Covid-19, the emergency operation centers (EOCs) will be activated and they won't be able to function virtually. The EOC for Covid-19 has been virtual for the most part, but it changes for natural disasters. You have to make the common operating pictures as robust as possible and you're going to have to be there to do it—at least for parts of the response. Some of the EOC folks are coming from places that are very prepared for these things. For example, we've seen police departments with their own supply chains for custom masks. You see many agencies with their own source of masks, so hospitals might not need to provide them for everyone. It would be advantageous to consider a discussion with expected volunteers pre-event though. Understand the needs and adjust accordingly.

    Soistmann: We're running close on time, so I wanted to leave the final question open to you. Is there anything else that we didn't specifically cover that we should? Any piece of the planning strategy we missed?

    Murphy: One of the most essential things I don't believe we touched on is to look at the health of your providers. They're invaluable assets. I'm concerned not only about physical health and protection from infection, but also the burnout rate. They have been going non-stop for a long time. There should be a focused effort to cycle them off and get some much needed – and deserved – down time. Hospitals should bring in mental health experts to assist with that. Not only is that burnout based on their daily jobs, but the lack of childcare, schools, camps, etc. has been exhausting mentally, making sure children are okay and taken care of, even though your job is essential. Having some way to take care of frontline providers is necessary because they're our lifeline. 

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