BY: JEFF MOSELY, PE
On the morning of July 10, 2019, the command center opens at Our Lady of the Lake Regional Medical Center in Baton Rouge, La. Tropical Storm Barry's journey across the Gulf of Mexico is varying in intensity and direction. The local weather coverage, a constant companion in the command center for the next four days, is predicting with more confidence that the storm will become a hurricane before landfall near Morgan City, La. The on-land projected route takes Hurricane Barry west of Baton Rouge by midday Saturday. More concerning is a projection of rain that could exceed 25 inches by the end of the weekend. At this point, our incident command center located in a room off the administrative offices has only partially activated the logistics and planning section chiefs, but that will soon change. An uneasiness begins to form in the incident command center as everyone there has been down this road several times before.
Our incident command members are keenly aware that the weather predicted could lead to traumatic stress for those on our team. Louisiana has endured more natural disasters than most states, 72 declared disasters since 1953. Time in Louisiana is still measured as "before Katrina" or "after Katrina," due to the loss and catastrophic damage from that 2005 hurricane. And just three years prior in August 2016, Baton Rouge had one of its worst floods in recorded history. Over 30 inches of rain fell in some parts of the region. Approximately a third of the businesses and homes had some form of flood damage, including those of many employees and patients of Our Lady of the Lake. Our command center opens when the administrator on call makes the determination it's needed. For this situation, as Wednesday morning turns to afternoon, the incident command is coming into its full complement of section chiefs, who are hospital employees with particular areas of expertise. There's comfort in knowing they are highly experienced in emergency preparedness and response.
HOSPITAL EMERGENCY PREPAREDNESS
Hospital emergency preparedness is the process of being prepared for any adverse event, natural or manmade, that can endanger the safety of patients, visitors or employees. At Our Lady of the Lake it is referred to as our "culture of preparedness." The facilities operations department is inevitably at the center of this preparedness. Events that could affect safety (known as adverse safety events) come in many forms other than weather. They can include mass casualties, an active shooter or loss of critical utilities such as information systems or electronic medical record systems. In all these examples facilities operations has a prominent role, not only in the preparation, but also in managing adverse events as they are unfolding. This preparedness comes from intense training, policies and drills. The Joint Commission requires as part of its hospital accreditation at least two drills per year. In 2018, we conducted four drills, plus had one actual event in which the incident command was activated. All emergency preparedness is structured within an emergency management program. The objective of the emergency management program is to identify processes for managing the effect of emergency events to hospital operations. These are highlights of the plan:
- A hazard vulnerability plan is completed annually to identify and prioritize potential natural, technological and/or human emergency events that may affect demand for or the hospital's ability to respond to demand for services. The process includes an evaluation of mitigation and preparedness activities of the physical plant, as well as response and recovery strategies.
- The hospital uses an incident command structure that is compliant with the National Incident Management System structure. The Federal Emergency Management Agency's National Incident Management System provides ways for government, nongovernmental organizations and the private sector to work together. The hospital's command structure is consistent with the command structure in place at other health care facilities in East Baton Rouge Parish, the most populous parish in Louisiana. It includes the city of Baton Rouge.
- Training for team members about incident command begins in general orientation and is included in annual education that can include classes, webinars and drills. Hospital leaders, including managers, directors, division directors and senior leaders are assigned incident command training. In the facilities department, team members learn utility loss protocols and pre-event precautions.
- All members of the command have other jobs at the hospital; we call in the section chiefs as needed, based on a potential disaster or emergency. Leaders with assigned roles in the command structure also complete two courses, one on the National Incident Management System, and one on the National Response Framework. These courses are for those who need a basic understanding of the National Incident Management System.
- At Our Lady of the Lake, the role of the incident commander rotates to the administrator on call when an event happens. The person holding the role may change once the incident command is activated if specific competencies warrant a change in leadership.
Our Lady of the Lake has a designated emergency management coordinator who functionally resides in facilities services, reinforcing the close relationship between emergency preparedness and the built environment. This coordinator manages all emergency preparedness activities and chairs the emergency management committee. As part of our emergency management program, the hospital has a written emergency operations plan that describes the response procedures to follow when emergencies occur. This includes recovery strategies and actions designed to help restore the systems critical to providing care, treatment and services after an emergency. Each of these response plans includes facilities protocols and is required training by all team members. The code colors can vary between states and even between different systems in a region, so drills include work to familiarize people with the different code names and responses. Some of the key response plans are as follows:
- Code Gray — Inclement Weather (Hurricane, Tornado, Ice Storm, etc.)
- Code Black — Bomb Threat Plan
- Code Red — Fire Plan
- Code Purple — Information Systems/Telecommunications Failure
- Code Orange — Chemical Contamination Plan
- Code Green — Radiation Plan
- Code Yellow — Mass Casualty Incident Plan
- Code Silver — Active Shooter/Hostage
After every drill and actual event, the hospital conducts an after-action review or "hot wash." The purpose of this meeting is to learn what went well and identify opportunities for improvement. This is part of a sustainability program to ensure policies and procedures are followed and are still relevant. After Hurricane Gustav in 2008 caused a 33-hour power outage at Our Lady of the Lake, the after-action review recommended increasing the emergency power through increased generator capacity to accommodate all power needs including the heating, ventilation and air conditioning systems. Our Lady of the Lake was within three hours of evacuating patients due to lack of air conditioning when the power was restored. Today, Our Lady of the Lake has five 1,750 kilowatt natural gas generators that can handle the entire facility's power needs. It's critically important: In 2018 a U.S. Senate inquiry faulted state and federal oversight agencies for fatal heat strokes when nursing homes were without air conditioning after several hurricanes that year. No other essential system in the built environment is more important than emergency power reliability and capacity.
Perhaps every after-action review ever conducted will identify issues with communication and recommendations for improving it. We have several policies in place regarding communications. The hospital prepares for how it will communicate during emergencies, including plans for notifying staff when emergency response measures are initiated. As a result of feedback concerning communication gaps during events, Our Lady of the Lake rolled out a text alert system in 2016. This system allows for carefully selected text communications to be sent to all those staff who opt into the alerts. Communication systems are among the most important systems to be maintained. For that reason, these systems including all information technology systems, are connected to uninterruptible power supplies. Equipment connected to these supplies does not have a 10-second delay in power as do items strictly on emergency power. Other forms of communication include:
- When the hospital responds to a disaster situation, personnel within the hospital are notified by overhead paging that announces the appropriate emergency code.
- Mass alerts are issued electronically to computer workstations via emails and our intranet home page.
- Ongoing communication to staff is provided electronically with the team member text alert system and regularly scheduled briefings for department leaders, who give employees updates. Medical staff communicates with patients and their families.
Hurricanes are unique in that they can give ample time for hospitals and health systems to begin their preparations and are a good example to use in describing the emergency preparedness process. The actions of the emergency preparedness teams leading up to a hurricane event are methodical and slower paced than response to other potential disasters, because more lead time is available. Also, hurricanes encompass all aspects of emergency preparedness from transportation, facilities, staffing and supplies.
THREE DAYS BEFORE HURRICANE BARRY
A tropical storm watch (soon to be hurricane watch) is issued for the Baton Rouge region. This means that a hurricane could be expected to pass through the Baton Rouge area within 72 hours. The administrator on call, an experienced Louisianan with more than four decades of emergency preparedness experience, has assumed the role of incident commander. For this event, the facilities lead is the logistics section chief. The incident commander in consultation with the Lake's chief operating officer and other executive leadership decide to activate a "Code Gray-warning." The incident commander first initiates a partial activation of the command center including just the logistics, planning and public information officer section chiefs. The public information officer, in consultation with other command staff and the chief operating officer, begins issuing early communications to staff. Three years after the 2016 floods, some in the Baton Rouge area are still traumatized, so there is sensitivity in all communications to our team members. The goal is to not be too alarming, but still emphasize the need for a culture of preparedness. The initial communications to all staff via emails and a called department head meeting indicate that we are watching the weather situation closely and to:
- Validate that your current department call tree is accurate and complete.
- Confirm your supply inventory is adequate and appropriate.
- Reinforce that our mission calls us to be a healing and spiritual presence. We encourage supervisors to support their team and provide the calming spirit they need.
- The ever-present opportunity to request sign-ups for text alerts.
Facilities operations, in addition to these tasks, begin their 72-hour pre-hurricane protocol, which includes topping off diesel fuel tanks, clearing the hospital site of debris that could become projectiles and touching base with all of their supply vendors and contractors for standby support.
48 HOURS BEFORE
The weather reports related to Tropical Storm Barry indicate Baton Rouge may get 15-25 inches of rain, which concerns staff more than the wind. It cannot be emphasized enough how difficult it is for dedicated, caring staff to concentrate on our patients' needs when memories of their own personal hardships from 2016 are ever present in their minds, but they do! "The Lake," as locals call the health care system, is a caring ministry dedicated to helping those most in need and the spirit of healing. With two days out from Hurricane Barry's landfall, a lot of emphasis is on the logistics section of the incident command. If the "Code Gray-activation" is issued, hundreds of staff will be required to stay on site until the code is lifted.
The logistics section begins preparing a sleep plan for staff. Fortunately, a plan is already in place that utilizes conference and clinical exam rooms as sleep rooms. Our Lady of the Lake has 832 licensed beds but does not allow staff to sleep in unoccupied patient rooms during a Code Gray-activation. We also are connected to several medical office buildings with hundreds of exam rooms. These medical office buildings are on the hospital's emergency power, including air conditioning. Under the sleep plan, the outpatient clinics would be closed if a Code Gray is called and beds would be available. After the 2016 flood we gave every employee who had an office an air mattress to keep on site. Hundreds of others were purchased and stored by facilities operations. The planning section of the incident command works on a distribution plan to get air mattresses into office and exam spaces.
24 HOURS BEFORE
The confidence level that Tropical Storm Barry will hit landfall around Morgan City, La., is high. The likelihood of 25 or more inches of rain hitting Baton Rouge is high. At this point the operations section of incident command is opened as well. The planning section of the incident command finishes its activation plan, which outlines steps for core and support departments and personnel. Our Lady of the Lake, like some other institutions, no longer uses the terms "essential and non-essential" when describing core and support departments out of recognition that everyone's job is important. Each core department, as well as the incident command itself, develops an A and B team to work in 12-hour shifts. Once Code Gray-activation is announced, all core teams are required to stay on site. The daily communications remind those core personnel to be prepared to stay by packing sleeping provisions, personal items and, most importantly, prepare things at home for their absence. Code Gray-activation was announced for 7 p.m. the evening before Barry is due to arrive.
HURRICANE BARRY ARRIVES
As expected, Tropical Storm Barry became Hurricane Barry on Saturday, July 13 at approximately noon, then shortly thereafter made landfall near Morgan City, La., as a Category 1 Hurricane. What happened next was not expected, and to this day is still not fully understood. Miraculously, the storm seemed to dissipate as it made landfall. It would later be attributed to a high-level dry air current that sheared the storm and dried up most of the moisture as it made landfall. The Baton Rouge area was spared the predicted rainfall and gusty winds. Later on Saturday afternoon, we were able to communicate that activation would be lifted by 7 a.m. Sunday morning and the recovery phase (relief teams) would begin. Relief teams take on shifts and give activated teams a rest. In prolonged incidents, relief team members may assume roles in the command center. Incident command was deactivated as well.
CONCLUSION
An after-action review was conducted the following Monday. Perhaps because the brunt of the storm never materialized or because we were prepared for the worst, there were very few issues raised. Facilities operations housed over 900 team members for two nights and received great reviews in the management of beds and bed locations.
These events shape who we are and how we manage our operations during a disaster. I recall sitting in the incident command during the flood of 2016 watching heartbreaking news coverage about those who had lost their homes. I will never forget one gentleman whose neighbors had showed up en masse to help him save his personal belongings. He told the reporter that God doesn't send money, he sends people. Those words will stick with me the rest of my life. When I spend days that can seem endlessly long in the command center, I see employees doing their jobs with a skill and compassion second to none. It reminds me that God really does send people to aid those most in need.
JEFF MOSELY is the vice president of construction and facilities operations for Our Lady of the Lake Regional Medical Center. Related facilities include more than 900 beds in four hospitals in Baton Rouge, La. In his role, he also supervises facilities emergency management for the region.