On the morning of Sept. 11, 2001, Leonard Aubrey, president and chief executive officer of NYU Downtown Hospital, New York, was at his desk in his ground floor office replying to an e-mail he has long since forgotten when he heard an explosion so loud the concussion shook the building. He went outside to look and saw smoke and fire engulfing the north tower of the World Trade Center three blocks away.
Gail Donovan, executive vice president and chief operating officer of four-hospital Continuum Health Partners, was meeting with other executive staff members in the 19th- floor conference room of their corporate headquarters uptown when they haplessly became a captive audience to an unobstructed view of the exploding towers.
Four floors below Donovan, Susan Waltman, senior vice president and general counsel for the Greater New York Hospital Association, received a call from the city's Office of Emergency Management informing her that there had been a major explosion at the World Trade Center. As prearranged in the city's emergency-preparedness plan, the GNYHA was to send someone down to the command center. Waltman says she flew into automatic and never even thought to run to the south side of the building to see for herself.
Paul Karis, M.D., was in Los Angeles, packing up his life in preparation for a cross-country move to New York where he was to become the new systemwide chairman of emergency medicine at eight-hospital Saint Vincent Catholic Medical Centers.
That same sunny morning, Mary Thompson set off to work at Bellevue Hospital Center where she is COO, remarking to herself that it "was one of the nicest days I've ever seen. On this kind of day, all is well with the world, and I should have stayed at home."
For all New York hospitals, it was a seminal day that changed them and their staffs in varying but profound degrees: financially, physically and emotionally. As a group, the events thrust them, as Waltman says, to the still evolving "front line of the nation's public health defense system." In the ensuing months, as they have struggled individually to bring some semblance of normalcy back to their traumatized hospital operations, they also have worked collectively to distill lessons from the still unbelievable terrorist attacks and prepare themselves--if that is possible--for the next unexpected disaster.
Photographs of long lines of empty stretchers waiting outside hospital emergency rooms dispassionately painted the tragedy of Sept. 11 from the perspective of New York hospitals: a horrifying lack of casualties to treat. In total, New York and New Jersey hospitals saw about 7,200 patients, the vast majority suffering minor injuries that did not require hospitalization. "We were not terribly challenged on 9-11 as a medical system," Aubrey says.
But the events served as a wake-up call. Considering the what-ifs--what if it had been a bioterrorism attack; what if there had been thousands of casualties--New York hospitals almost immediately recognized the need for regional emergency planning, including a reliable and comprehensive communication network among hospitals. The events also spawned a newfound appreciation for the work that hospitals do and the crucial role every employee plays.
"There has not been a day where we have not respected what we went through on 9-11," Waltman says. "All I've done since last September is help hospitals prepare . . . . The community has taken every lesson it can possibly learn."
Financially speaking, NYU Downtown was arguably the hardest hit of all the city's hospitals, walking a tenuous line between being part of the rescue effort and being a victim itself. That fateful morning, the now-storied hospital, which serves the Wall Street community, was squarely facing a $3 million loss for the year. As the twin towers collapsed within 23 minutes of each other, 149-bed NYU Downtown provided medical care, hot meals and refuge to the fleeing hordes while running on generators and seven telephone lines. With subway lines down and traffic patterns disrupted, the chokehold on the surrounding neighborhood bonded the hospital to its community.
But the access problem stretched into weeks and months, severely limiting the flow of patients. Aubrey says it doesn't readily reveal itself on the hospital's balance sheet, but to this day private and faculty physician practices are feeling the effects of a smaller workforce in the neighborhood. Inpatient surgeries and obstetrics have never bounced back like before, most likely because street access from nearby Chinatown is still being rerouted, he says. As a result of all of this, by Jan. 1, the hospital's deficit swelled to $11 million: $2.6 million directly as a result of the event and $5.4 million in lost revenue, according to Aubrey. Aubrey says he is hopeful that much of the $8 million will be recouped through federal funding earmarked in large part for New York hospitals, but there is still a toll (April 8, p. 6).
"The frustration with us is the time it has taken to do the applications, and the fact that everyone wants to be the last payer," Aubrey says. "We have found that the time and effort it takes to get cash in the door is very difficult and very stressful." The hospital takes small comfort in a $4 million bank line of credit, a cushion that it is keeping as a last resort and is closely guarded by his chief financial officer, Aubrey says.
"There is no question there are a host of challenges ahead," he says.
Looking forward, NYU Downtown has embarked on a "broad and deep" strategic planning process, Aubrey says. Every open position is scrutinized and with the help of consultants, hospital officials are studying how the facility will fit into the downtown Manhattan community. "There's nothing that's not on the table," he says.
With the exception of NYU Downtown, New York hospitals for the most part escaped the physical destruction of the event, although several lost ambulances--and far worse, the paramedics who drove them. New York-Presbyterian Healthcare System lost nine vehicles and three people, says Herbert Pardes, M.D., its president and CEO. All told, the system lost about $13 million as a result of the attack, he says, even though its closest facility lies far uptown.
But the physical impact of Sept. 11 on hospitals reveals itself in more subtle ways. Like almost every office building in New York, all hospitals have beefed up security--a challenging proposition for quasi-public institutions that want to welcome patients, not scare them away. It's especially delicate at Bellevue, which as a public hospital has a large homeless patient population. Before Sept. 11, unattended bags were a common sight at the hospital, Thompson says. Now they are reported immediately. The hospital has hired 17 additional security officers and gates have been locked down, limiting points of entry. At the same time, she doesn't want to turn Bellevue into "a fortress," Thompson says.
"We've developed an awareness here and are going to a culture where we have to protect each other. We are not there yet, but there's a big, big difference," Thompson says. "Yet I still want to maintain this as a place you want to come to if you are sick. I still want that fuzzy, patient-centered feeling."
Living with bioterror
Coupled with the anthrax scare that followed the World Trade Center disaster, New York hospitals now consider bioterrorism a hard reality, and that's also changing the look and feel of the institutions. Hospitals are reconfiguring emergency rooms and buying new equipment to better prepare for any future catastrophes. Bellevue plans to build a decontamination chamber that can accommodate 200 people per hour, and there are now two Geiger counters in the ER.
NYU Downtown, which was planning a new ER before Sept. 11, has revamped its designs, increasing the anticipated $25 million cost by several million, Aubrey says. Revisions include a larger decontamination unit and a redesigned floor plan with more open spaces to accommodate a large influx of patients. Planners are even thinking about things "as mundane" as making sure they have enough tags on hand to identify large numbers of patients and collect information, Aubrey says. They also are reconsidering the windows, which failed to protect the hospital from the choking cloud of debris that surged through the neighborhood after the towers collapsed.
Systemwide, Saint Vincent has invested more than $1 million in equipment and supplies to prepare for another disaster. Karis says it probably has cost another $1 million in salaries to train staff.
Approximately 150 employees in emergency services have taken a 16-hour "train the trainer" course on responding to nuclear, biological and chemical disasters, says Bernadette Kingham, Saint Vincent's vice president of communications and development. Thousands of others have taken two- and four-hour classes to prepare for nuclear events.
"There are folks like me who were always worried about disaster preparedness--we just get taken a lot more seriously now," says Lewis Kohl, D.O., chairman of emergency medicine at 402-bed Long Island College Hospital in Brooklyn. "We were trying to get hospitals and health systems talking about smallpox months before, and there was a tendency for some administrators to roll their eyes and hope we would go away. At least they don't roll their eyes at me anymore."
Since Sept. 11, with the help of $50,000 in donations collected from the community, LICH, which is part of Continuum, has purchased personal protective equipment for clinicians, outdoor decontamination showers, Geiger counters and chemical-weapons detectors, Kohl says.
"We've redefined the word disaster," Donovan says. "In the past a disaster was a 12-car pileup on the highway or a major malfunction of a building system."
Like the other hospitals, Donovan says another much more appreciated aspect of emergency preparedness is recognizing that all employees must be brought into the fold. The system undertook a massive education effort aimed at creating "a spirit of security among our workforce based on some of these horrific things they could be presented with," she says. Continuum produced a 30-minute video with personal accounts of what "we experienced as an institution (on Sept. 11)," she adds. That led to extensive discussion on what it means to be ready for the unknown, Donovan says.
The lessons learned in New York have not gone unheeded nationally. Last October, a group from the Joint Commission on Accreditation of Healthcare Organizations visited the four hospitals hardest hit by the attacks: Bellevue, Beth Israel Medical Center, NYU Downtown and St. Vincent's Hospital Manhattan. Aubrey also was invited to speak at the JCAHO's annual surveyors' conference in January.
"What struck me in all cases was the tremendous impact that the catastrophe had on staff, (but not) their ability to function at such a high level," says Russell Massaro, M.D., the JCAHO's executive vice president of accreditation operations. He adds that he was most affected hearing about the experiences at NYU Downtown--how the staff soldiered on in spite of fears of contamination and their own personal safety. "As I talked to them, chills went up and down my spine," he says.
The JCAHO discussion inspired the formation of New York's Emergency Preparedness Coordinating Council, a model in regional hospital planning. Donovan, who wanted to continue the talks within the city after the JCAHO left town, planted the seed of the idea, Waltman says.
Beginning early last November, the GNYHA acted as the catalyst in bringing together the working group of the highest echelons of hospital administrators and public health officials. The council has met in some fashion every week since, Waltman says. Among other things, it has produced briefings on personal protective equipment and decontamination units and an emergency contact directory containing crucial information about every facility in the event of a disaster, including contact names and what resources are available. The council also has seen to it that every hospital will stay in touch through a powerful radio system that also connects to the city's Office of Emergency Management. Last month, some 60 people attended a council debriefing in which they discussed a recent smallpox scare at Beth Israel Medical Center-Kings Highway Division. The GNYHA is in the midst of posting the vast stores of data collected in the months since Sept. 11 on a publicly accessible Web site.
"We are unquestionably better connected with each other and better able to communicate, collect information about needs and resources, and better able to assess where patients are going and what doctors are seeing," Waltman says.
If there has been one overriding change in mental attitude in the New York experience, it has been the realization that no hospital is an island. People and hospitals nationwide responded to NYU Downtown's valiant effort with heartfelt letters and small tokens of appreciation. Cards and letters from schoolchildren around the country arrived by the cartons. Staff members from a hospital in London walked in off the street one day and presented Aubrey with a loose-leaf book full of good wishes, he says. NYU Downtown also was the recipient of 10,000 teddy bears sent by sympathetic residents of Oklahoma City. The bears were quickly dispersed to the "waiting hordes" through an admittedly "flawed distribution system," he says. Only one remains in the hospital: A life-size teddy bear wearing an Oklahoma State shirt sits in a corner in Aubrey's office.
"A hospital is just not within the four walls," Aubrey says. "I certainly feel good about what was done, and I feel more intense about this institution and the value we can bring to this community."
Saint Vincent's Karis says he came to his new job last fall with the idea that emergency planning was up to individual hospitals and thought perhaps 10% of his worktime would be devoted to emergency preparedness. It's more like 90%, he says.
"You can't fool yourself into thinking you can handle it by yourself anymore. It's bigger than any one hospital can handle," Karis says.
Thompson of Bellevue says there is an upside, even though the comfort zone that existed before Sept. 11 is gone and things no longer can be taken for granted.
Recalling what started as "a beautiful day" one year ago, Thompson says, "How do I live my life? Fully. I'm very thankful for everything--for my staff, for the flowers that grow, for the people I meet. I'm just grateful each day. We have survived, and we're stronger."