Expect the unexpected: How we recovered operations after Hurricane Harvey

Whatever your facility’s disaster management plan, it needs continual refinement to account for the differences between imagined and real scenarios. Hurricane Harvey, which hit Houston hard on Saturday, August 26, 2017, is a case in point. The storm brought more than 60 inches of rain within a couple of days, 68 deaths, and $125 billion in damage—second only to Hurricane Katrina—Abigail Caudle, MD, MS, told attendees at the 2019 OR Business Management Conference.

Dr Caudle is executive medical director, perioperative services, at the University of Texas MD Anderson Cancer Center in Houston. MD Anderson has 44 ORs where more than 20,000 cancer operations are performed annually.

Harvey caught the hospital a little off guard because it landed earlier than anticipated and lasted 2 to 3 days, Dr Caudle says.

“We had about 500 patients and 1,000 employees in the hospital when the hurricane hit. Usually in these situations, you double up on staffing with designated ride-out teams [staff who volunteer to be on call during an emergency]. But since the storm came earlier than expected, we only had our normal weekend staffing in place,” she says.

About a third of employees had significant damage, with cars or homes ruined, and the only way to reach the hospital in the first days was by boat. This made it impossible for additional staff to reach the hospital for several days. The first relief came on Tuesday, when additional staff were able to reach the hospital, and the staff who had been at the hospital could leave.

“We had flooding in sterile processing, which meant ceiling tiles were coming down and everything was contaminated. We had limited staff to re-sterilize the instruments. About $100,000 worth of supplies was ruined,” Dr Caudle says. Fortunately, some case carts had already been moved upstairs to the ORs, and some supplies were available from the ambulatory surgery center across the street.

The geographical area of Houston is a bit larger than New Jersey, and most MD Anderson patients aren’t local, Dr Caudle notes. Even those who come from Texas may travel quite far to get there, and when the storm hit, many patients were in nearby hotels awaiting surgery. Despite the skeletal crew and damaged equipment, some procedures were urgent, so Dr Caudle and her colleagues had to act quickly.

“We have a pretty robust incident command system, based on a FEMA [Federal Emergency Management Agency] model, which means reporting three times a day,” Dr Caudle says. “We go through key areas of the hospital and try to match resources with need.” FEMA training is mandatory at MD Anderson for staff who are part of the Institution Incident Command system (https://training.fema.gov/emicourses/).

Multiple huddles throughout the day on Monday gave leaders and staff a structured way to assess resources and prioritize cases, starting with a directors’ huddle at 6 am and ending with a 7 pm huddle of the hospital’s Institution Incident Command, Dr Caudle says.

“We had about 350 cases scheduled that week, and we didn’t have the instruments or the staff to do them. Given the limited staff on hand to process instruments, we predicted that we could only do 10 cases per day once our sterile processing department was operational,” she says. “We asked the surgeons to prioritize their cases, and everybody pitched in.”

Surgeons rated cases as:

critical—an inpatient in a life or death situation
urgent—patients who came from out of town or perhaps were involved in an oncologic trial
elective—patients who could safely have surgery in the next 2 to 3 weeks.

“As we prepared to go live, we reviewed each case to make sure we had staffing, instruments, and supplies ready. We also contacted ancillary services like radiology, pathology, and the blood bank,” Dr Caudle says. After facility repairs were made on Tuesday, two inpatient cases, one of which was a multi-surgeon spine case, were performed on Wednesday. Twelve cases were done on Thursday and 20 on Friday.

Abigail Caudle, MD, MS

After that first week, Dr Caudle says, ongoing recovery involved rescheduling cases. “We worked with our IT [information technology] partners to facilitate a process. We suspended our block scheduling rules; we allowed surgeons to swap out cases. We were proactive about scheduling urgent cases first.”

“Our OR capacity tool was very helpful—this shows in advance every day of the week how much capacity is in the ORs. By week 3, we completed 75% of canceled cases. Some [elective] cases were pending reschedule, and about 3% of cases were canceled,” she says.

MD Anderson’s emergency planning manual includes:

A checklist of items to prepare and where to get them, such as toiletry kits, food, water, and cots
A list of tasks and assignments. For example, 96 hours before an event, the Institution Incident Command team reviews par levels and confirms ride-out teams, and at 72 hours prior, it provides patient phone numbers to surgical teams and notifies patients.
Incident Command System & policies
Emergency numbers, ie, cell phone numbers (including IT support)
Scenario-specific resources. For example, in case of fire, where are the fire extinguishers located, and where are the emergency numbers to call? If computers go down, what kind of paper system do you have as a backup?
Ring Line instructions: A phone number to call to see if staff should report to work.

Dr Caudle advises reviewing and updating this manual on a yearly basis.

“When you know a disaster is coming, plan and communicate the plan repeatedly,” she says. “Have OR schedules printed, and know where the patients are and their contact numbers. During Harvey, on Sunday morning we realized we had to cancel Monday’s cases, and no one could get into the hospital. Getting access to this list of patients and their contact numbers was a challenge.”

Communication with surgeons and anesthesiologists during the storm was effective, largely because of their smart phones, Dr Caudle notes. “We sent email communications once or twice a day. We were very transparent about the damage to sterile processing, and we gave them directives about how to help with the schedule,” she says.

Communication with staff was more challenging because many did not have access to their institutional e-mail accounts at home or on their phones. This meant that managers had to contact staff individually, which was a time-intensive process.

Perhaps one of the biggest lessons learned was the lack of redundancy in sterile processing. “We had started to build a second site in our ambulatory surgery center across the street, but it was not completed at the time when we needed it,” she says. This second site is now completed.

“The recovery process involves prioritizing, eliminating roadblocks (for example, breaking rules like block scheduling), paying overtime for staff who can get to the hospital, communicating constantly about progress, and keeping records of everything you’ll need for insurance,” Dr Caudle says. She adds that it’s important to realize the “understanding” period is brief; in the immediate aftermath of a disaster, surgeons may be forgiving of delays, but before long they will expect things to be back to normal.

“When disaster arrives, first take a breath. Make patient safety the priority. Assess the damages and resources, and communicate. Then start planning for recovery,” she says.

Quoting the late tennis star Arthur Ashe, she advises: “Start where you are. Use what you have. Do what you can.” ✥ Elizabeth Wood

Reference
Caudle A. Riding Out the Storm: Managing Operations in the Wake of Disaster. OR Business Management Conference, 2019.