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Perspective |
1 All authors: Department of Radiology, Ochsner Clinic Foundation, Ochsner Medical Center, 1514 Jefferson Hwy., New Orleans, LA 70121.
Received November 3, 2006; accepted after revision November 21, 2006.
Address correspondence to E. I. Bluth.
Keywords: emergency planning • radiology practice
Having successfully managed the department of radiology at the Ochsner Clinic Foundation during the recent events of Hurricane Katrina, we thought it would be valuable to share and discuss key information regarding management during a catastrophe.
Management during a catastrophe can be divided into three components: preplanning, managing the actual event, and modifying the emergency plan according to lessons learned from the previous event.
The Ochsner Clinic Foundation is a 532-bed tertiary care academic medical center with 20 radiologists, 22 residents and fellows, and more than 300 other personnel within the radiology department on the main campus. Before Hurricane Katrina, we had had many previous hurricane alerts at Ochsner, and we updated our emergency plan regarding equipment, personnel, emergency power, and communications annually. The overall institutional plan called for key individuals to stay in the institution for 2 days after the hurricane struck and then evacuate by helicopter to safety. This plan had previously been communicated to and accepted by the whole institution, including the radiology department.
Preplanning: Personnel and Equipment
The department of radiology conducts yearly reviews to determine the radiology equipment that would need to be available on emergency power. We decided in June 2005 that we needed to have two digital radiograph rooms, one CT scanner, two sonography units, one angiography suite, two emergency department radiology rooms, and a PACS with two workstations all deployed on emergency power. In addition, it was decided that portable equipment should be moved to essential floors such as the medical, neonatal, cardiac, and surgical ICUs and the transplant unit before the expected arrival of the hurricane in case the elevators would not function.
Knowledge Gained
From previous experience, we filled 55-gallon drums with water. These drums
were deployed to the bathrooms to flush toilets in the department. In
addition, we stored a considerable supply of bottled water within the
department for drinking. At Ochsner, a water well independent of the city
intake supply was to be used as a backup for toilets and showers. This
arrangement occurred as a result of other experiences in which the city water
intake failed.
Personnel
The radiology department updated yearly the teams of required personnel
based on services to be offered. In previous hurricane dress rehearsals, we
realized the need to have enough personnel to allow shifts so people could
sleep. We planned for two 12-hour departmental shifts. In addition, in June
2005 we decided that, based on the mix of equipment and specialties to be
offered, for emergency in-house call we required three staff radiologists,
three residents, 16 technologists and support staff, one information services
(IS) individual, and a service engineer to deal with unforeseen problems with
equipment. We identified a Team A and discussed the need for a Team B.
However, a Team B was not named before the hurricane. Personnel on Team A were
told to have their families evacuate elsewhere and only bring family members
to Ochsner if there was no other alternative. In addition, personnel were
instructed not to bring pets into the institution, although this was difficult
to enforce. Personnel were also told to bring food and clothes for a 2-day
stay because that was the institutional plan.
Emergency Power
The Ochsner Clinic Foundation had three emergency generators, and the
department administrator made sure essential equipment was online. Outlets
connected to emergency power were red instead of white and were easy to
identify. Flashlights and electric lanterns were stocked for emergency
deployment.
Communication
The institution publicized a free 800 telephone number for evacuated
personnel to make their evacuation whereabouts known. Before the hurricane,
the department also collected emergency numbers for home telephones and cell
phones. In addition, the institution had some wireless telephones (PTB 410,
SpectraLink) to be distributed to leaders in the radiology department and
other departments throughout the institution.
Managing the Actual Event
On August 24, 2005, the National Weather Service was uncertain where Hurricane Katrina would go. On August 25 and 26, the hurricane was expected to move toward the western coast of Florida or northeastern section of the Florida panhandle. On Saturday, August 27, the National Weather Service changed its forecast. It became clear that the hurricane was expected to come to the New Orleans metro-politan region. The departmental emergency plan and the institutional emergency plan were implemented on August 28. The individuals who were on Team A were required to come into the facility with their clothing, food, and water. The rest of the members of the department—and the rest of the city of New Orleans—were requested to evacuate elsewhere. On Sunday evening, when the whole emergency team was in place, all the studies were dictated in anticipation of the power outage.
On Monday, August 29, 2005, Hurricane Katrina struck New Orleans with 175-mph sustained winds and 216-mph gusts. Ochsner Clinic Foundation Hospital lost electricity when the hurricane struck on Monday morning at approximately 6:00 am. Of the three emergency generators on hand and connected, only one worked as planned. Two main feeders were lost because of the storm. Therefore, the institution at first had limited and then no air-conditioning and light on Monday morning. The temperature reached more than 90°F during Monday afternoon.
As a result of the limited air-conditioning, the central institutional computer server room overheated and the central server had to be shut down, thereby eliminating our PACS. To review and report on images obtained, we had to print films for radiographic interpretation and use workstations to access CT studies. For sonography image review, we used the machines themselves to assess the images. Because electronic reporting of images was no longer possible, preliminary reports were handwritten and maintained in hard copy for referring clinicians. All reports and images were stored in one central location, which was communicated at the leadership meetings. Also, to simplify notification procedures, we assigned one pager that was handed off from resident to resident as the shifts changed.
The city was devastated by the levee breaches that occurred 3-4 hours after the hurricane passed through the city. The flooding impacted approximately 80% of the city. The severity and extent of the flooding isolated the city and delayed relief efforts. Media reports of civil disobedience and lawlessness caused considerable fear among staff members in the hospital and delayed relief efforts. When a convenience store near the Ochsner Clinic Foundation Hospital was looted, great alarm spread among the staff members regarding their safety. On Monday afternoon, the National Guard was taken from Ochsner to conduct search and rescue, leaving only Ochsner's internal security. This caused additional consternation until Thursday when eight National Guardsmen were redeployed to Ochsner.
Later on Monday, additional emergency generators were ordered via existing telephone lines, but trucks carrying them were turned back by the Federal Emergency Management Agency (FEMA) and not allowed to enter the city. The city water intake did not work, and we switched to our emergency well water for bath-rooms and showers, as planned. Water and food were limited but in adequate supply in the hospital. Concern was expressed regarding the well water running dry, so personnel were asked to reduce the length of their showers. The well water did not actually become available until some time on Tuesday. The Ochsner Clinic Foundation had stored only a 2-day supply of food and water. When senior management realized that external relief would take much longer than 2 days, they communicated with outside vendors who allowed Ochsner personnel to buy needed food and water supplies by leaving IOUs.
On Tuesday night, after a radio address by Mayor Ray Nagin in which he told everyone to expect 12-15 ft more water in the city and advised everyone remaining to evacuate via the Crescent City Connection bridge across the Mississippi River, it was decided to quench the MR units. The process of quenching the magnets was difficult because of the lack of emergency power. Fortunately, the mayor's predictions did not come true.
Within 2 days, the personnel of the radiology department managed to connect all essential imaging equipment to two of 27 workstations in two different rooms, bypassing the IS server with extension cords. This allowed the department to operate more easily and facilitated image review by the referring clinicians. Power was restored on day 4 and air-conditioning on day 5.
The Ochsner central administration held leadership meetings, including radiology department leadership, two or three times per day. Leaders were highly visible and even served meals in the cafeteria. Radiology communication was organized by having departmental meetings two times per day after the Ochsner administrative meetings. This was a successful way to quell fears and eliminate rumors.
While Team A was working onsite, the chairman, who had evacuated, was actively attempting to contact all other professional members of the radiology department. This process began on Monday morning (the day of the storm) and by Tuesday afternoon, Team B was selected as well as components of Teams C and D. Special care was taken to balance the skill mix of the teams and to appoint an appropriate team leader. The membership of Teams C and D was finalized by Thursday.
The initial expectation after day 1 of the hurricane was that relief Team B would arrive in 7 days. However, the stress became too great for Team A and the team was relieved by day 6; as a result, Team A spent 5 nights in the hospital. Some of the problems arose because the family members, including small children, of team A had been evacuated to distant locations for a much longer period than the initially planned 2 days. Team B had to use commercial transportation, which was difficult and expensive to arrange. There was no organized airline travel help for these needed personnel through any relief agency. In some cases, individuals drove private cars to a common site for busing into the New Orleans Ochsner campus. Automobile travel was difficult, however, because of the lack of open gasoline stations. There was no special help for returning physicians.
Outside communication was a major problem. Cell phones with local New Orleans numbers did not work because cell towers had been blown down by the hurricane. E-mail servers were overloaded, and it was difficult to gain access to the Ochsner e-mail system from outside. However, outside e-mail through companies such as AOL did function, although this did not allow communication with radiology management. Telephone numbers in the radiology department were usually busy and calling in was difficult. The institutional 800 number for evacuees to call with their whereabouts was overwhelmed and not easily accessible. It was difficult to establish contact with the relief Team B as well as with Teams C and D. It was also difficult to plan transportation back into the city on day 4 or 5. Among other things, as previously mentioned, gasoline for private cars was limited.
Examination volume was much lower than expected. There were only 130 examinations in the first 4 days. In the first 2 days, there were only a few radiographs and very occasional sonography and CT examinations. By week 5, the volume had returned to approximately 800 examinations per day, which was the level before the hurricane. Teams of radiologists, residents, technologists, and support personnel were brought back to work based on the volume of activity as analyzed and predicted by radiology management. We started with Teams A, B, and C with three staff members and three residents for 5 nights and 6 days. After 2 weeks, teams were switched to groups of 4, 7, 10, and then full staffing based on an analysis of procedure volumes in real time.
In contrast to other medical facilities and businesses in the New Orleans region, all salaries and benefits were maintained by the Ochsner Clinic Foundation during the hurricane. However, downtime was considered as vacation. Because the Ochsner administration wanted to limit the number of personnel on active duty, it was up to the radiology administration to show the need for additional staff as it brought the department back to its full staffing levels.
Lessons Learned for Future Emergency Plans
Equipment
Concern about the water well running dry during an emergency led the
Ochsner administration to drill an extra water well. We now accept that the
emergency stockpile of food and water should be sufficient for 7 days. We plan
to add emergency power to all MR scanners to monitor cryogen levels and ensure
a supply of chilled water. Since the MR scanners are on the first floor, there
was concern that they could be flooded. These scanners were not placed on
emergency power before the storm. However, we now realize that to quench the
magnets more easily and safely, emergency power to the equipment is necessary.
It was also decided to connect the second CT scanner on the second floor to
emergency power for redundancy and to ensure that if the first floor flooded,
a CT scanner would still be available. The drums of water were not effective
in flushing toilets. Because a second water well has been established, filling
water drums will be discontinued in future emergencies.
Personnel
We have now determined that we need to organize Team B before evacuation
and that members of Team B should expect to return in 6 days from the time of
the event without being contacted. In addition, all personnel have now been
made to understand that they must call in after they have evacuated and make
their whereabouts known. Before a hurricane, all personnel will be asked to
update their contact information and anticipate their evacuation location as
best they can. Personnel will also be asked to bring not only warm weather
clothing but also cold weather clothing as well. When the air-conditioning was
finally reestablished, thermostats were nonfunctional initially and the
temperatures were very low. Additional actions will be needed to limit the
evacuation of pets onto hospital grounds.
We have also realized that there is a need for more psychological support for emergency teams. Management needs to deal with many psychological problems experienced by personnel during the different stages of the catastrophe. There is no way to easily predict who will be greatly affected by stress during a real emergency. An important lesson, which was reaffirmed, was the need to have a service engineer and IS personnel in an emergency on-call status within the institution. After a few days, we realized the need to monitor examination volumes after a catastrophe to bring in the appropriate volume of staff members in real time. One other important lesson learned is that some personnel will immediately relocate after a catastrophe of this size and will not return. Alternative staffing plans need to begin immediately.
Emergency Power
It is important to have redundant generators on hand. The Ochsner Clinic
Foundation has now purchased several additional generators. But just in case
some of these fail, it is strongly advised to have many large extension cords
on hand for unforeseen needs.
Communication
A new central call-in number in the radiology department for use by staff
has been instituted. There will now be a central command location within the
radiology department so that everyone can easily locate other individuals. The
use of frequent meetings to communicate information, allay fears, and
eliminate rumors cannot be overemphasized. Repeating information to ensure
comprehension is valuable.
Management During a Catastrophe
The need to be open and honest with staff members regarding known
information cannot be over stressed. It is strongly advised to communicate
facts often and in a repetitive manner. Personnel need reassurance in times of
high stress. Ongoing meetings twice a day were effective in relaying
information and eliminating rumors. This practice will be continued in future
emergencies. Because there were such problems with communication by local cell
phones, we have now decided to buy and have on hand cell phones from other
cities. Also, additional Internet servers have been added by our IS
administration to enhance and ensure e-mail communication.
Conclusion
The most important lessons learned for future planning are that leaders must be patient and flexible in face of adversity. Departments must continuously review, update, and improve plans before a catastrophe. However, it is difficult, if not impossible, to preplan for all contingencies. Those in charge should be optimistic during the event whenever possible. This can be an important source of energy for staff members. And last, and perhaps most important, to manage successfully in a hurricane, communication and high visibility must be the first priority of the management team and all leadership.
Acknowledgments
We appreciate the contributions of our colleagues Kenneth Bell, Judy Champaign, John Kalmar, Arthur Kenney, Merikay Long, Christina Milborn, James Milburn, Julie Sossaman, Lamar Teaford, Moises Yoselevitz, and all members of Teams A, B, C, and D to the material in this article.
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