Recovery mode

As superstorm Sandy made landfall, the water that surged toward Long Beach (N.Y.) Medical Center knocked through bricked-over windows and punched holes through walls, easily pouring over a 3-foot-high concrete barrier along the hospital's northern wall built 20 years earlier to keep out floodwaters from an adjacent channel.

Until late October, the 142-bed hospital had withstood decades of hurricanes and nor'easters, largely without flooding. Now hospital officials frankly acknowledge what had worked previously will not be enough.

A generator will be moved from the basement. So may the boiler. “And we'll be raising those barrier walls that we've erected, which are now 3 feet, to probably around 6 feet or maybe even more than that,” said Douglas Melzer, the hospital's CEO.

More than a month after superstorm Sandy devastated flood-prone communities in New Jersey and New York, five hospitals cannot admit patients because of damage that destroyed electrical systems, flooded emergency and exam rooms and crippled elevators. New York state has asked federal officials for $3.1 billion in federal aid for hospitals and other healthcare providers damaged by the storm.

Now, as hospitals severely damaged by the storm race to rebuild and reopen their inpatient services, hospital executives are drafting plans to better defend against future forceful storms as experts convened by state and city officials work to devise recommendations in coming months that could force hospitals to meet new standards for storms with winds of an even greater magnitude.

“It will require regulations” to better prepare hospitals for future storms, Dr. Irwin Redlener, co-chairman of a New York state commission on preparing critical services, including hospitals, for natural disasters. “Not only will it require regulation, it will require much more proactive oversight” of compliance, said Redlener, who also is director of the National Center for Disaster Preparedness at Columbia University. The regulations will need to address not just generators, but electrical and fuel systems critical to their operation. “There's going to have to be inspections on a regular basis and a lot more detailed oversight than people have been used to in the past,” he said.

New York City Mayor Michael Bloomberg announced last week that the city would draft plans to protect critical infrastructure—including hospitals—from Category 2 hurricanes, which have winds of 96 to 110 mph. Sandy made landfall near Atlantic City, N.J., after being downgraded from a Category 1 hurricane with winds of 80 mph.

Bloomberg cited a map of Sandy's floodwaters, which overlapped with federal projections for flooding on a scale so rare that it is known as a 500-year flood. “As you can see, the yardstick has changed and so must we,” he said.

Bloomberg also ordered a review of the storm mobilization and response by hospitals and other critical services, with recommendations expected in February.

“Everyone thought we had 20 years to prepare for this, not two,” said Russell Unger, chairman of the Building Resiliency Task Force that was convened in November by New York City to draft recommendations by next summer. Hospitals and nursing homes will be “very much” a part of the group's review of critical buildings as they draft recommendations, he said.

The lethal storm that barreled into New Jersey and New York in late October exposed ways large and small that hospitals were vulnerable to floodwaters, forcing an emergency evacuation of one Manhattan hospital, knocking out elevators and water at another and leaving yet another to operate for days on limited backup generators without enough power for electric toilets and pneumatic tubes that whisk samples from doctor to laboratory.

“I don't think it was obvious before how dependent we were on the basement,” said Dr. Nathan Link, medical director of Bellevue Hospital Center in Manhattan, which was evacuated after the storm and is not expected to resume admitting patients until February. It is now able to offer some outpatient services.

Critical hospital equipment at or below ground level—from generators to the pumps and switches needed to fuel and distribute emergency power—was destroyed as the storm's hurricane-force winds pushed water across city streets and over barriers.

During the storm and in the days afterward, as more hospitals damaged by flooding closed, roughly 1,300 patients were evacuated from hospitals. Dozens of hospitals lost utility power across New York and New Jersey, leaving them to operate on emergency generators, in some cases for days, as executives, doctors and nurses were forced to react and adapt.

“I can't overemphasize how many decisions that were made on the fly,” said Dr. Gregg Husk, chairman of emergency medicine at Beth Israel Medical Center, which remained open, but operated on backup generators for six days.

As construction crews strip damp wallboard from hospital hallways, engineers and executives say they will raise or add barriers and relocate essential systems and consider how to build in more redundancy for essential services—from telephones to power supply—to better survive the next powerful storm.

“Getting everything out of the basement would be ideal,” said Mark Healey, director of facilities and engineering for the Long Beach Medical Center, which is on a barrier island alongside Long Island.

Sandy flooded Long Beach Medical Center's basement—home to clinics, its kitchen and sterile supplies, as well as essential electrical and boiler equipment—with 10 feet of water. Groundwater continued to seep into a subbasement and basement rooms holding mechanical equipment more than four weeks after the storm.

In November, Long Beach Medical Center opened a temporary emergency room in heated tents and trailers. Last week, the emergency room was replaced with a mobile primary-care clinic.

“This was an extraordinary event,” with damage unlike anything seen in his 36 years with the hospital, Melzer said. “So we will prepare for an event such as this going forward, but this was just an extraordinary event.”

The combined cost of repairs to the hospital and other hospital property and remediation for future storms could total $21.2 million, said Barry Stern, chief financial officer for Long Beach Medical Center. Meanwhile, lost revenue from the hospital and its nursing home totals roughly $1.85 million a week. The hospital's and nursing home's flood insurance is limited to $1 million combined, and its business interruption insurance will provide another $1 million. The hospital will rely on state aid and relief from the Federal Emergency Management Agency. “We didn't really have the kind of reserves that would allow us to weather this storm on our own,” Stern said.

Officials with other hospitals damaged by the storm have announced similar rebuilding plans.

An overflowing East River filled the subbasement of the Veterans Affairs Department's Manhattan hospital, and floodwaters rose higher than 5 feet in the basement, destroying its electrical equipment and fire-safety system. It's unclear when the hospital, which is in an area designated as most vulnerable to flooding, will reopen; its outpatient services are not expected to resume until March.

Martina Parauda, director of the VA New York Harbor Health Care System, said the hospital will move electrical switch gear, medical gases and vacuums. “Whatever can be moved up will be moved up,” she said. Plans under way before the storm to build a flood wall may need to be revised and raised, she said. “It sounds pretty crazy in Manhattan that we would need a flood wall, but we are an island,” Parauda said.

Officials at NYU Langone Medical Center, which lost power in the hours after the storm reached New Jersey and was forced to evacuate, declined an interview request. NYU Langone's backup power failed, forcing workers at the Manhattan hospital to carry patients down dark stairwells to empty the building after water breached fuel tanks and triggered sensors to shut down fuel pumps that feed generators, an initial analysis of the failure showed. The 786-bed hospital said in early November that an outside expert would review the conclusions. Officials said last week that they expect the hospital to begin readmitting patients, though not fully, by the end of the month with “nearly all services” available a month later. The hospital has been able to resume some outpatient services.

At Bellevue Hospital, floodwater that rushed into the hospital's basement dislodged elevator doors and knocked out electricity to pumps that deliver fuel to the 788-bed hospital's generators, which are on the 13th floor. Generators continued to operate with fuel hauled up stairs by employees and the U.S. National Guard.

Alan Aviles, president and CEO of the New York City-owned health system that includes Bellevue, said remediation plans would relocate electrical switches, fuel pumps and other critical infrastructure, such as power distribution, water and communication systems, that were vulnerable to flood damage.

The hospital, which lost its water and elevators before officials opted to fully evacuate after the storm, will also rebuild to ensure some elevator shafts are not vulnerable to flooding, he said. But Aviles said the system's first priority will be to reopen its hospitals. Flood-proofing will follow.

“We're going to have to do some of that at a later point, yet we're going to have to do that with urgency once we get past this initial challenge of getting the hospitals up and running,” he told an audience in mid-November at the Crain's New York Business: Health Tech Summit. “It will be expensive.”

Coney Island Hospital, which like Bellevue is owned by the New York City Health and Hospitals Corp., also was not admitting patients weeks after the storm, but was expected to resume in early January. Some outpatient services are now available. The 371-bed Brooklyn hospital had no power for about four hours during the storm. First the hospital lost utility power during the storm. Then advancing floodwaters prompted officials to pre-emptively shut off the generator to prevent damage, said Daniel Collins, director of facilities for the hospital.

The generators will be raised and electrical switch gear, which distributes power, and water supply pumps will be relocated from the basement, but remediation plans won't be finalized until immediate repairs are made and the hospital reopens, Collins said. He said the city's plan to reconsider its flood zones could affect the hospital, but it's unclear how.

Changes in response to the storm are not limited to hospitals closed by Sandy.

Beth Israel Medical Center, an 810-bed hospital in Manhattan, did consider an emergency evacuation after losing its utility power during the storm and one generator temporarily failed. An evacuation ultimately was not necessary, officials said, but the storm's severity and the hospital's nearly weeklong dependence on generators will prompt a review of its power sources and preparations.

Already, officials at Beth Israel, where electric-flush toilets and pneumatic tubes did not work on generator power, say they see ways to adapt.

Nurses navigated dimly lit hallways with glow sticks and flashlights—but headlamps allowed nurses to keep their hands free. “Those were like gold around here,” said Mary Walsh, Beth Israel's vice president of patient-care services and chief nursing officer, who said supplies for future blackouts could include more headlamps.

FEMA dispatched additional backup generators to the hospital as days stretched by without a return of utility power, said Ken Holden, senior vice president for real estate and facilities at Continuum Health Partners, which owns Beth Israel. But connecting those external generators—which ultimately were not needed—would have been highly complex and could have required a day or longer to complete. The hospital will seek to develop a simplified connection, akin to a plug-in, for future use, he said.

Continuum's existing co-generation power plant at the Brooklyn campus of Beth Israel and another plant planned for its Roosevelt Hospital in Manhattan could be modified for less than $2 million to give the hospitals independent sources of power in the event of another utility power failure, Holden said, as long as natural gas lines are not affected.

Holden said the hospital must prepare for future floods. “While today I am not in a flood zone, I don't know what the weather is going to be in 2022 or 2032,” he said. (See commentary by Continuum Executive Vice President and Chief Operating Officer Gail Donovan.)

Bloomberg said last week that the city would re-examine its flood zones and would also work with the state to bolster incentives for hospitals to produce their own heat and power.

Redlener, the co-chairman of the state commission on critical services, said critical support systems for emergency power supplies in New York hospitals were vulnerable but did not need to be so after the lessons of Hurricane Katrina. “These are lessons that should have been learned prior to Sandy's arrival,” he said. “Almost everything that we experienced in Sandy had been previewed seven years ago in the Gulf.”

Hospitals should be required to retrofit existing buildings to meet new standards, he said.

Patients in hospitals—or nursing homes—are dependent and vulnerable, Redlener said. “This is not just an office building,” he said. “This is a concern of the state and the city because there are lives at stake. The public interest is what's at stake here.”

Hospitals closed by storm damage also strain the healthcare system. “The closing of hospitals, especially big busy hospitals, is an unbelievable burden on the community and other hospitals that remain open,” Redlener said. “The other hospitals are in a chronic surge situation.

TAKEAWAY: After Sandy, public officials and hospitals should reconsider how much is enough to defend against powerful storms.