June 23, 2020

Jeffrey Elder, MD—emergency medicine physician at University Medical Center, Clinical Associate Professor at Louisiana State University School of Medicine, and former Administrative Director and Medical Director of New Orleans Emergency Medical Services—recently spoke with Advisory Board's Alice Thornton Bell, APRN, senior director, and Rebecca Soistmann, analyst, about how hospitals should proactively prepare to manage hurricane response amid Covid-19.

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

Question: Thank you for joining us today, Dr. Elder. We really appreciate it. Before we get into our questions, can you share a bit more about your background?

Jeffrey Elder: Of course. I'm an emergency physician, I was the Administrative Director and Medical Director for New Orleans EMS for eight years. I left about two years ago and am now full time at University Medical Center as faculty with LSU Emergency Medicine. I'm the Medical Director for Emergency Management in the hospital, and I do some emergency response work for our hospital system, which is LCMC Health. Since Covid-19, I've been working at the both the hospital and system levels on Covid-19 response and emergency management.

Q: Now, Hurricane Katrina was a defining crisis for New Orleans. How did that crisis shape how you collaborate with private and public entities for large-scale events?

Elder: Dealing with FEMA, because of Katrina, the New Orleans region was forced to really work together. Before that, everyone was siloed and there was limited coordination between hospitals and parish governments for hurricane shelters.

So now we use emergency command centers (EOCs) and Incident Action Plans (IAPs) for many of our planned events, like Mardi Gras, the Super Bowl, big concerts, etc., and we get together fairly often as a group. And after Katrina, we developed the Metropolitan Ambulance Council, which meets on a bi-monthly basis and includes representatives from all 911 responders, both private and public ambulance services. We built an ICS system, and we also have our regional group of health care providers that meet with the designated regional coordinator (DRC) to keep up on disaster management plans. The DRC is the main linchpin between parishes, the government, and hospitals.

Having systems in place like this is an advantage when you have to turn on this emergency response system. I've said this for years now, if you have those personal relationships built in, it's so much easier to communicate up and down the line and across the structure.

Q: I think most of us learned a lot during Katrina—but Covid-19 is a different-in-kind challenge. What was the response like to Covid-19 in the early days of the epidemic?

Elder: We had our big hit early in March. We received our first patients on March 10. Then, pretty quickly, everything ramped up. We peaked in the first and second week of April, it was our make-it-or-break-it timeframe. Our hospital put up extra ICU beds and med surge beds and postponed all non-emergent care and ambulatory surgeries.

But ever since, we've had a significant decrease. At UMC, we probably had about 200 patients at the height of Covid-19 in our hospital, which is down to about six today. Our hospitals are starting to go back to normal operations. All the safeguards—limited visitors, masks, etc.—are still in place, but we're getting back to routine operations. The state and the city got on the ball with shutting down fairly early.

And as Louisiana enters Phase 2, to keep our numbers flat, we've been proactively testing people; I'm involved in testing at the regional level, and we've been doing low barrier community testing. We're also going into nursing homes and shelters to do testing there to make sure we're not having spikes in these congregate living spaces.

Q: Considering where you've been and where you are now, what's top-of-mind for emergency management in terms of Covid-19 right now? And what advice do you have for others along the coastline?

Elder: Hurricane season is something we're always planning for, and we get a bit nervous every year in June—and of course, having a storm the first week of June doesn't help with that. Tropical Storm Cristobal quickly got everybody in the mindset of handling a natural disaster. Everyone's been pretty mentally exhausted from the pandemic, and one of the big concerns is that people have been working at such a high level. Meanwhile, we're trying to get back to the "new normal," but we have this threat that could turn into a big incident if we get the wrong storm.

At the hospital, there are a few challenges we're planning for in addition to routine response:

For higher-level storms (strong Category 2 storms and up), the push in our region has been to discharge down as much as possible prior to a hurricane. You want the fewest number of bodies in the hospital by the time the storm hits. We don't have a lot of confidence that this will happen this season because there are less places to send people to. Nursing homes have been busy, so people are a little warier to take patients.

Second, although New Orleans has a pretty robust evacuation plan, it might be harder to implement this year, if needed, because the city will be pretty stressed as far as where people will go. Normally, mutual aid agreements and contracts with state governments allow hospitals to send folks to other hospitals, but now you have to cohort people based on symptoms and some places will be less likely to take people in.

Third, we also have to be ready for people to come to hospital last minute as a form of shelter. People are sick and their families may not know how to care for them or what to do, so they come to the hospital. We've seen this before, and we have to be ready for this. For some people, there will be no good options.

So, in case we can't get people out, we have to prepare some different "options of last resort." It's going to be critical for us to have staff already in the hospital and have PPE and supplies so that we're ready to be cut off from the rest of the world for five or more days.

Q: You mentioned Tropical Storm Cristobal, and I'm interested in how the city prepared for and managed that storm. Could you share what that situation looked like for your team?

Elder: The weather service was fairly certain that it wasn't going to get worse than tropical storm, so that allowed us to activate our lower-level storm response. The main threat from Cristobal was going to be heavy wind and street flooding. So, while we did activate Code Gray, the hurricane response plan, we didn't discharge down and there was no sheltering required. We did things like double-check generators, went through the plan, and made sure we had all supplies we might need. We told our employees they could stay at the hospital if they were concerned about flooding at their homes or in their neighborhoods, but few ended up needing that.

For a higher-level storm, we have a system where the staff is divided into teams, and Team A is required to stay at the hospital, Team B isn't. We didn't have to worry about that for Cristobal.

Q: If you encounter a more severe storm during the epidemic, are there any places still supporting Covid-19 patients that would normally become hurricane shelters in the event of a storm?

Elder: Post-Katrina, the city really tried to stay away from having shelters in town. People wouldn't leave the city, they'd just come to the shelter. The city's plan is to help get you out, rather than shelter people in the city, so that people will be persuaded to evacuate farther out. Over the past few years, the city has provided medical special needs shelters for people who don't have a place to go if they lose power and are medically dependent on electricity.

For Covid-19, we opened a 1,000+ bed center at the convention center for post-acute care. They started working on that in the middle of March, when it looked like Covid-19 was really taking off and we thought it would completely overwhelm the system. By the time the convention center opened, we were at the peak, so they took about 100 patients who were just not quite ready to go home or couldn't find a place in a nursing home. So, if there's a need for a hurricane shelter, we're thinking that the center could be a special needs/medical shelter or could help with nursing home evacuation.

Q: In our conversation with Dr. Murphy, he mentioned if a hurricane happened while the economy in New Orleans was still mostly closed, Incident Command could have asked hotels to house evacuees. Is that still possible as the city enters Phase 2? Are there other innovative solutions that could allow for social distancing in shelters?

Elder: We're still nowhere near capacity with hotels since they reopened, so one big option is vertical evacuation in hotels. New Orleans has over 10,000 hotel rooms since it's such a huge tourist destination, and they tend to be in places that are safer from flooding since they're at higher elevations. So, we'd still be able to do that.

Beyond hotels, there is a lot of planning for traditional shelters, utilizing more square footage per person. The problem there is that for the same building, you can take in less people. The other piece of that is thinking about cohorting Covid-19 positive people who aren't in the hospital and might come to a shelter. In the hospital, you might be able to use the same sleeping space for two people where one would sleep during the day and work the night shift and vice versa, but you might not be able to do that with Covid-19 concerns. So we're looking at how we can spread people out while they're stuck inside the hospital during an evacuation.

Q: Relatedly, Dr. Murphy also told us about triage plans during disasters. Are there any different protocols or ways to prioritize patients for transport when they are confirmed positive with Covid-19?

Elder: For almost all hurricanes, the plan is to discharge all the patients you can, and then hunker down with the patients who can't or shouldn't be moved. For instance, we know that there's additional mortality for ICU patients if you move them. And for the hospital, our entire first floor could flood but the rest of the facility could function. We'd be an island, but we could function. We'd have generator power for over a week.

With Covid-19, you might not be able to discharge as many and therefore have more people to care for during the storm. One caveat there is that we'll try to get NICU babies and dialysis patients out before the storm. That would be the first round of patients you'd try to evacuate. From there, you're trying to get lower acuity patients discharged.

Q: In addition to relocating patients, I imagine PPE will be a significant challenge. How has University Medical Center proactively prepared to handle PPE concerns during a natural disaster?

Elder: As a system, we look at our burn rate. The goal is to stockpile enough to sustain that burn rate for a certain amount of time, so we are trying to stockpile as supplies come in. While we're not rationing PPE like we did at the height of Covid-19, we are trying to get the message out there that people shouldn't throw PPE away. Now is the time to be careful about how you utilize your PPE. If we have a hurricane and Covid-19 at the same time, nobody's coming in with a truckload of PPE in the middle of a hurricane until maybe four or five days later.

Q: As we talk about a natural disaster happening in the midst of a second wave of Covid-19, what advice would you give to hospital leaders preparing for this dual threat?

Elder: Two things here: First, for those of us who were hit pretty hard with Covid-19, we know what works and what doesn't, we've looked around and stolen plans from other people, we know how to deal with it. Step one is that we have to be prepared for that: know your plan, have your PPE stocked, if you see a surge of patients, know who will be taking care of them and alert your staff early.

Second, you really have to review your tropical weather plan and think about what isn't going to work in the hurricane plan due to Covid-19, like shelters. We normally just have to prepare for a hurricane, and it was more siloed, but we must look at the threats in tandem now. So, you have to start talking to people in your network about how you'll manage both threats—and you have to do that proactively, before the threat arrives.

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