Disaster after disaster, hospital preparedness remains a deficiency

The COVID-19 pandemic was most people’s introduction to the critical importance of hospital emergency preparedness. However, while it is strikingly clear that prolonged surges of patients occur during infectious disease emergencies, hospitals must be prepared for “all hazards” that could impact them. An all-hazards approach is designed to foster resiliency in hospital to the wide range of threats they may face that include outbreaks of infectious disease, hurricanes, tornadoes, flooding, blizzards, mass casualty accidents, chemical spills, nuclear power plant accidents and myriad others.

The recent struggles of hospitals in Florida post-Hurricane Ian — some of which lost water, were flooded and needed to evacuate patients — are a concretization of this fact.

The most tragic consequences of lack of hospital preparedness occurred post-Hurricane Katrina at Memorial Hospital — immortalized in Dr. Sheri Fink’s “Five Days at Memorial” (now a television series on Apple+). In those dire circumstances, doctors were left helpless to care for patients and made decisions that no doctor would ever want to be in a position to make. Such events led to the development of crisis standards of care.

Similarly, but less dire, was the plight of hospitals and health care facilities in New York and New Jersey after Superstorm Sandy — a topic my colleagues and I studied extensively. In that event, a major academic medical center whose generators were below sea level and, consequently rendered non-functional by flooding, was forced to evacuate patients to various hospitals in the midst of the storm.

Hospital preparedness deficiencies for COVID-19 are too numerous (and too familiar) to list.

However, events such as these raise the question of why sufficient hospital preparedness remains a deficiency at many hospitals.

In most hospitals, emergency preparedness was often an afterthought, relegated to some minimally staffed office in some low trafficked area of the hospital and largely out of sight. Most emergency preparedness managers did not have any link to the executive management team of the hospital who often viewed emergency preparedness as a box to be checked, a single mass shooting exercise to conduct, and, above all, a cost (vs. a revenue) center. This lack of priority was and is a surefire path to being inadequately prepared.

This situation has somewhat improved post-9/11 and the anthrax attacks as dedicated programs were established at the federal level such as the Hospital Preparedness Program. Additionally, the Joint Commission and Centers for Medicare and Medicaid (CMS) put metrics and regulations in place. Hospitals in close geographic proximity began to form coalitions to support each other in emergencies.

However, many hospitals remain woefully underprepared for emergencies even after COVID-19. This will likely remain the case unless a reprioritization occurs. Much of the reprioritization must occur within hospitals themselves and will involve a reconceptualization that situates emergency preparedness and continuity of operations a core aspect of their operation.

Recommendations include:

• Emergency preparedness managers need to have direct lines of communication to hospital executives and be integrated into all hospital functions all the time, not just during emergencies
• Hospital coalition members should behave like coalition members and have protocols and policies in place for patient load-balancing — even if it involves transferring patients to competitors
• In geographic areas, all health care assets should be linked when it comes to emergency preparedness and be parts of coalitions. Primary care offices, pharmacies, dialysis centers, nursing homes, methadone clinics and the like should all be explicitly part of emergency planning at a regional level. State and local health departments and emergency management agencies should be seamlessly integrated as well.
• Hospitals should review their infrastructure and identify major and minor vulnerabilities (such as backup generators being below sea level) and work to remedy them
• Federal, state and local governments — who have stringent regulatory authority over most hospital operations including bed capacity — should robustly support, incentive, and facilitate these activities

The list above, although not comprehensive, may seem obvious and many hospitals might be engaged in these activities to some degree — but their level of engagement is clearly not enough as evidenced time-and-time again. Hospitals may be able to withstand a short-lived surge, but a prolonged surge or deficits in infrastructure are beyond the pale for most.

Hospital preparedness, like public health, is better thought of as an aspect of national security and be a perennial priority for every hospital. Cycles of panic and neglect will never suffice if resiliency to the next emergency we face is the goal.

Dr. Amesh Adalja is board certified in emergency medicine, critical care medicine, infectious disease and internal medicine. He is a senior scholar at the Johns Hopkins Center for Health Security. Follow him on Twitter: @AmeshAA