Storm surge: After Irma, Harvey and Maria, providers prep for a new hurricane season

Amanda Leite's daughter Nicole was running a fever while her family was shut in by Hurricane Irma.

The worst of the storm was tearing through the Orlando, Fla., area on Sept. 6, 2017, when Leite's 4-year-old was sick. It sounded like a train was barreling through their boarded-up house in Lake Nona, said Leite. She took shelter with her two daughters in a closet in the center of her home that's just big enough to fit a full-size mattress.

Leite wasn't sure if she should give Nicole ibuprofen because she had a bleeding disorder. She was scrolling through Facebook and found an advertisement for Jacksonville-based Nemours Children's Health System and its telehealth app. Nicole "hadn't been sick for years," said Leite, who had never used a telehealth service before. "It was scary. We couldn't leave, and there was a lot of uncertainty as to when we could get to a doctor."

Leite logged on and a doctor guided her via the camera on her phone, like a FaceTime call. She pressed on her belly, checked her throat and surveyed her stomach for a rash. Leite gave Nicole a small dose of ibuprofen and her fever subsided. "I will never forget that."

Leite was one of 2,100 people who downloaded the Nemours app over several days during the Category 5 hurricane, equivalent to the typical usage over three months. Nemours had the capacity and connectivity to help the influx of telehealth users around the clock, which is critical when patients and doctors don't have access to healthcare facilities, said Carey Officer, operational vice president for Nemours CareConnect. The organization offered free telehealth visits when its primary-care and specialty offices were closed during the storm and got the message out through its website and social media.

Still, the health system learned that it needed to adjust staffing volumes prior, during and after the storm. "Knowing what we know now, we can better staff our hospitals as the storm approaches, during the storm and after," said Officer, adding that visits spiked before and after.

The devastation wrought last year by hurricanes Irma, Harvey and Maria delivered a crash course on disaster preparedness for health systems and other providers. The 2018 hurricane season—which kicked off June 1—is expected to be "near- or above-normal," according to the National Oceanic and Atmospheric Administration.

As with nearly every new hurricane season, providers say they learned from years past and have plans in place to adjust staffing levels, improve communication with incident command centers, form stronger partnerships with first responders and other city and state personnel, bolster regional and interstate connections with other providers, and fortify their technology and building infrastructure. A recent poll from the American College of Emergency Physicians suggests otherwise, though.

Ninety-three percent of 247 emergency physicians surveyed by ACEP said their emergency departments are not fully prepared for surge capacity during a disaster. About half said they would be somewhat prepared; about a quarter indicated they wouldn't be completely ready; and 17% said they were completely unprepared. About three-quarters indicated they don't always have access to real-time data.

Even though the CMS emergency-preparedness rule that went into effect in 2016 spurred more planning, many providers are still lagging, said Nicolette Louissaint, executive director of Healthcare Ready, a disaster-response not-for-profit. "Preparedness and resilience aren't always priorities," she said. Providers often prioritize competing day-to-day operations over preparing for a potential disaster, she added.

Only 13% of those surveyed in the ACEP poll said their hospital has thoroughly re-evaluated preparedness plans; 44% said that they had done so to some extent. Twenty-two percent said they had not really re-evaluated plans and 8% said they had not done it at all.

Ochsner Health System in New Orleans ramped up its disaster protocol after Hurricane Katrina and the 2016 Baton Rouge floods. It has three tiers of staffing—Team A, Team B and Team C—which are built into its workflow. Team A is stationed at its facilities during a disaster while Team B evacuates, but prepares to return within 24 hours. Team C returns when normal operations resume.

This requires repetition and practice until these processes are ingrained, said Mark Dupuis, Ochsner's assistant vice president of system security and emergency preparedness.

"A lot don't realize the work that goes into this," he said. "You need to get as many people involved as possible—community partners, first responders, the local light company and vendors. You have to meet every year because you can't during a disaster."

Lower Keys Medical Center, which is owned by for-profit hospital chain Community Health Systems, was evacuated and closed during Hurricane Irma. The Key West, Fla.-based hospital focused on getting its ED open as quickly as possible after the storm because otherwise, first responders can't work.

During Irma, Lower Keys lost its "chillers," which operate the hospital's air conditioning. It has since bought more equipment.

Last year, the hospital worked with Monroe County officials to ensure critical hospital employees could get to the Keys during the storm. But some staff didn't have a place to stay, so for this year the organization has reserved 30 rooms at the area's only hotel deemed safe in a Category 5 storm, Clay said.

Lower Keys regularly performs evacuation drills with the National Guard, local naval air base and first responders. "Irma reinforced the value of preparing and having drills every year," Clay said.

Some ancillary and post-acute care facilities around Florida didn't reopen quickly or at all after the storm, which created some access and care continuity issues. Lower Keys is working with the community to form a more comprehensive plan for patients who may no longer need acute-care services but can't be discharged due to a lack of post-acute services, the organization said.

During Harvey, one of Houston's main dialysis centers closed down, which left Memorial Hermann Health System scrambling. "We tried to prioritize getting urgent-care centers opened as soon as possible," said Deborah Gordon, chief legal officer and chief administrative officer at Memorial Hermann.

During Harvey's peak, Memorial Hermann's nurse health line received more than 900 calls, many of which were from people who couldn't get through to 911 personnel. Bilingual nurses were able to help residents provide home care for minor injuries. They directed patients with less critical injuries to urgent-care centers once the roadways cleared and clinics reopened, which helped alleviate the stress on its emergency departments.

Memorial Hermann bolstered its infrastructure after Hurricane Alison hit in 2001. It added water-tight submarine doors as well as other structural integrity features. But many systems haven't kept up regular infrastructure maintenance, according to the ACEP survey.

Thirty-six percent of respondents said there have been infrastructure improvements related to disaster preparedness within the past five years. Eighteen percent said within 10 years, 3% said within 15 years and 7% said it has been more than 15 years.

Memorial Hermann is adding more robust internal communication tools to reach displaced employees. It used an internal social media site during and after Harvey to make sure its staff had access to mental health resources, construction and repair services, among others.

The health system is also readying an 1135 waiver application, which provides emergency credentialing for out-of-state clinicians. In 2017, an 1135 waiver also help deliver critical medications to patients during Harvey, the system said.

Cleveland Clinic Florida plans to reactivate its ambulatory sites more quickly, said Osmel Delgado, chief operating officer of Cleveland Clinic Florida. The system will keep its command center running longer after the storm to improve communication.

Finding child care for hospital staff is also critical during a storm, Ochsner's Dupuis said. Ochsner has accommodations for staff, family and pets in most of its facilities. Employees can also find basic supplies in its "OchsMart."

Amid the chaos of a disaster, it's important to appreciate the little things, Delgado said. Cleveland Clinic set up a room for the children of employees who were taking shelter as Irma ripped through South Florida, he said. They fired up Netflix, made popcorn and set up arts and crafts tables.

"It was a breath of fresh air," Delgado said. "You almost forgot what was going on outside."