Four years after the terror attacks of Sept. 11, 2001, hospitals across the country continue to struggle with contingency plans for dealing with a large-scale natural disaster or an attack by extremists inside America's borders, many officials say.
Those limitations were starkly evident when Hurricane Katrina swept through the Gulf Coast late last month, hobbling hospitals across the region -- including a half-dozen in New Orleans alone -- and triggering the deployment of temporary healthcare facilities in Louisiana and Mississippi. Even with days to prepare, state, local and federal officials were unable to deploy medical teams or establish temporary facilities until about 48 hours or more after the full effects of the storm were felt.
While some incremental progress has been made in preparing the healthcare infrastructure for worst-case scenarios -- and Katrina certainly fits that definition -- the healthcare industry remains largely ill-equipped to handle the consequences of a major catastrophe. What's more, just weeks after Katrina's devastation, Hurricane Rita was charging toward the Gulf Coast last week.
"The healthcare industry is definitely better-prepared than it was three or four years ago, but there still is a significant way to go," said Mark Smith, chairman of the emergency medicine department at Washington Hospital Center and the medical director of ER One, a proposed national prototype for a so-called "all-risks ready" treatment facility.
"We need innovation. We need to be doing things differently. It's important that we don't just do more of the same. We're dealing with new types of threats we never imagined 10 or 15 years ago. And the design of emergency departments reflects the reality of 10 or 15 years ago.
"We're in kind of an awakening phase," Smith said. "And we have a lot of work to do."
Confronting these new and troubling threats, some industry observers and healthcare administrators have begun to shift their focus to unique concepts such as ER One or "surge" hospitals, a still-developing model based on the idea that hospitals must be prepared to rapidly expand services either at existing facilities or at designated nearby sites equipped to handle an overflow of patients.
The devastation in New Orleans and elsewhere along the Gulf Coast presented a logistical nightmare for the healthcare system. Nurses hand-pumped ventilators for patients because there wasn't fuel available for the back-up generators. Hospital personnel struggled to carry patients up and down dark stairwells because there was no electricity. And with 80% of the city flooded at one point, hundreds of patients were airlifted from hospitals by helicopter crews, who were threatened by gunfire in at least one instance.
Yet even though surge capacity is meant as a response to large-scale disasters, it did not necessarily apply to Katrina under its most commonly accepted definition, some experts said. Surge hospitals are designed to expand medical capacity to meet the needs of an unexpectedly sharp increase in the patient population. And even the best-laid plans would not have provided much relief after one of the worst natural disasters in the nation's history left the area's public-health system near collapse.
In the case of Katrina, there was simply no place to put patients.
"I think this experience with surge hospitals should be used to go back and look at some of the assumptions of people who want to spend time and effort on the idea of separate surge hospitals, whether they're permanent or mobile," said Jim Bentley, senior vice president for strategic policy planning for the American Hospital Association. "We need to do some assessment and determine why we didn't need what people thought we'd need after a flood like this."
In one respect, the need for surge capacity did become evident in the grim aftermath of Katrina when the federal government established a huge triage center, along with a makeshift morgue, at Louis Armstrong New Orleans International Airport in suburban Kenner. Other sites across the Gulf Coast were transformed into latter-day MASH units, including the parking lot of a Kmart in Waveland, Miss., where a team of healthcare personnel from North Carolina set up a $1.5 million mobile treatment center, complete with a 1,000-square-foot emergency department and four intensive-care units.
After experiencing Katrina, planners probably will start looking at surge capacity with a far broader geographical scope, said Sally Phillips, director of bioterrorism and public-health preparedness research at the Agency for Healthcare Research and Quality.
"I think there are always lessons to be learned from any situation," she said. "I think we've always been thinking about these issues in terms of regional preparedness. But this has taught us that our regions are bigger than we thought."
In Katrina's wake, hundreds of patients from New Orleans were transported not only to hospitals across the region but also to temporary facilities in Baton Rouge, La. The rapid deployment of several facilities in Baton Rouge was an excellent example of the effectiveness of long-range surge hospitals, said Paul Carlton, a physician and a former U.S. Air Force surgeon general who is director of the office of homeland security at the Texas A&M University System Health Science Center in College Station.
Carlton, a retired lieutenant general who was on the ground in Louisiana's state capital for about three days to help in the rescue effort in early September, said healthcare officials, local disaster planners and others set up four surge hospitals in a day or so. One quickly established surge center involved expanding capacity by about 200 beds at Earl K. Long Medical Center, where several closed wards were opened for the evacuees.
Meanwhile, a few blocks away, on the campus of Louisiana State University, two athletic facilities were transformed into a surge hospital capable of handling about 1,500 patients and a nearby shuttered Kmart was transformed into a 1,000-bed hospital, Carlton said. Most of the facilities were bare-bones in terms of medical equipment, although the 14,000-seat Pete Maravich Assembly Center at LSU housed 19 ventilator patients.
"The concept worked perfectly," said Carlton, a big proponent of surge hospitals, of the situation in Baton Rouge. "It was proven with three examples of different types of surge facilities. One was in place at the hospital, where staffers quickly expanded capacity. Two were `buildings of opportunity,' and a third (example) is a closed building or facility that's reopened to meet demand."
He acknowledged that the practical concept of surge hospitals failed in New Orleans, but only because of the sheer magnitude of the catastrophe. "The entire local response was destroyed," he said.
The AHA's Bentley said the relocation effort caused considerable stress for only about a day before the healthcare system in Baton Rouge was able to absorb the influx of patients. "It was maybe 24 hours that the system was stressed," he said. "As far as I can tell, the system was able to cope."
While Katrina might trigger a renewed concentration on preparing for the worst, concerns over costs -- among other issues -- could continue to hamper any full-scale national effort to address how best to deal with a massive natural or man-made disaster. HHS, working with the Homeland Security Department, has created task forces to try to determine proper capacity levels at hospitals around the country in case of major emergencies. Under HHS guidelines and a National Response Plan, all hospitals are required to have a certain amount of "surge capacity," which is defined as the "ability to rapidly expand beyond normal services to meet the increased demand for qualified personnel, medical care and public health in the event of bioterrorism or other large-scale public health emergencies or disasters."
Among other preparedness plans, the agency has sponsored pilot projects in some states to develop comprehensive data banks of all medical personnel to ensure that these professionals are available in an emergency. At the same time, the Health Resources and Services Administration, like the AHRQ a division of HHS, is working with the states to develop plans to meet a set of 16 benchmarks for surge capacity by the end of fiscal 2007. Those plans, which are being directed by state officials with oversight from the federal government, include general requirements that hospitals identify surge capacity for everything from beds and manpower to equipment and connectivity.
"We are improving -- absolutely ," said the AHA's Bentley. "Are we where we ultimately want to be? No."
Bentley said most people define "surge" hospitals as mobile facilities designed to supplement existing hospitals in the case of an emergency. One type is portable and self-contained, a stand-alone facility that could be rapidly assembled to meet the needs of victims. The other kind, he said, is a "facility of opportunity" -- an airport hanger, an empty warehouse, a large auditorium -- that can be reconfigured as a temporary hospital in much the same way that the New Orleans airport was transformed into a triage center.
The focus on surge hospitals predated the terrorist attacks of four years ago in New York and Washington. Healthcare experts and architects in Houston began discussing strategies after floods spawned by Tropical Storm Allison in June of 2001 closed down several major hospitals and forced the evacuation of scores of patients.
"That started the discussion of whether our healthcare facilities are able to deal with these kinds of major events," said Greg Hughes, healthcare-market-segment leader of the architectural firm of Perkins & Will and a founding member of the American Society of Healthcare Architects who was involved in those early discussions. "We started talking about what sort of a network do we have to have in order to respond to major shutdowns, or major impacts on the system."
In late 2004, several variations on the theme of surge hospitals were showcased at Texas A&M University, where students in the college of architecture created a series of "hospital conversion" projects that were unveiled during a visit by U.S. Surgeon General Richard Carmona. In addition to using available local facilities like amphitheaters, students also proposed reconfiguring hotels, motels and local schools for use in emergencies.
Texas hospitals have worked aggressively in recent years to develop their surge-capacity outline under HRSA guidelines, Carlton said. The planning phase often isn't too difficult, he said, pointing out that one Austin hospital asked for his help in determining how to meet a requirement for a 112-bed expansion. Carlton said he did so by recommending the conversion of a day-surgery center, which immediately added 127 beds. Another part of the planning process, he said, calls for transforming a veterinary hospital in College Station into a surge hospital, a process that "would get us 700 beds in an hour," Carlton said.
"The whole idea of a surge hospital or surge capacity is to create something out of nothing," he said. In Carlton's view, this kind of relatively simple, inexpensive conversion will appeal to cost-conscious hospital administrators concerned about spending huge sums to deal with a threat they may never experience. "It hasn't happened here (in Texas and most other parts of the nation), so people tend to think they don't have to deal with it," he said. "So, my job is to encourage some level of preparedness, to at least do the `low-hanging fruit' that won't cost a lot."
Just how far the healthcare industry is prepared to go depends pretty much on "how much we bleed" after a subsequent attack or another natural disaster, Carlton said.
In a bit of a twist on surge facilities, some experts believe entire sections of hospitals should be retrofitted in a way that enables the facility to quickly expand services and space in an emergency. That's the idea behind ER One, the scalable emergency department at the Washington Hospital Center.
The project, still under development at the medical complex about two miles from the U.S. Capitol, would be capable of "scaling up" operations to handle five times the typical number of patients during the first two hours of an emergency. Capable of handling 350 patients simultaneously, it features universal patient rooms configurable for any purpose, modular equipment, 100% air filtration, built-in radiation protection and blast-protected walls.
ER One has received about $3.5 million in federal funding, and is scheduled to receive about $25 million more in an appropriations bill pending in Congress, but it has a ways to go before officials can fund the cost of more than $100 million as part of a broader project at the hospital. At this point, it's still stuck in the "concept phase," Smith said.
He estimates that top-of-the-line facilities, such as those envisioned by ER One planners, will cost about 30% more than traditional emergency departments. "The country is hungry for newer and better ways of dealing with threats of terrorism," Smith said.
While ER One remains in the planning phase, the momentum behind surge hospitals has slowed somewhat as the industry sorts out several key issues. Of course, the stumbling blocks are highlighted by cost, the AHA's Bentley said. He said hospitals have to decide whether to spend money to cope with something that might never happen or pay for equipment or expansion to deal with the illnesses and common medical conditions they see every day.
"Every dollar that the healthcare system has that it spends on preparedness is one less dollar that it can use for care for the uninsured, or to upgrade technology," Bentley said. "For a hospital board, the decision might come down to spending money for, say, a specialized maternity program that people will use the day it opens."
This story originally was published in the Sept. 26 issue of Modern Healthcare.