Planning for disaster
Can Virginia's hospital emergency rooms handle a catastrophe?

by Marjolijn Bijlefeld and Robert Burke
for Virginia Business
November 2006

When Tropical Storm Ernesto blew into Virginia in early September, Sentara Williamsburg Regional Medical Center had been open for just two weeks. The rough weather gave Don West, the hospital's director of support operations, a first-hand look at possible strains on the system in the event of a larger emergency. After high winds knocked out power, the hospital's generators kicked on while the main electrical transmission line between Yorktown and eastern Richmond was repaired.

Overall, Sentara Williamsburg — built to withstand 110 mph winds — came through in good shape. "When you work in a hospital, you're used to disasters," says West. "Something's going to happen."

Today that "something" could be a lot worse than a tropical storm. Terrorist threats, an outbreak of pandemic or avian flu or a natural disaster on the scale of last year's Hurricane Katrina loom as potential public-health disasters. They would require a massive response from health-care providers.

Virginia – a coastal state, next-door neighbor to the nation's capital and one of the few states to actually experience a terrorist attack when a plane hit the Pentagon on 9/11 – needs to be at the front line of readiness. So, are we ready? Does Virginia have the facilities, training, personnel and supplies to respond adequately to a catastrophic disaster?

In terms of an immediate response, the answer from experts in the field is a tentative yes. Fueled in large part with $50 million in federal funds since 2002, Virginia's hospitals have been beefing up. Communication networks are in place between state and local public-health officials and hospitals to gauge the severity of an emergency. Such networks would allow officials to decide quickly which hospital has available beds, or space to quarantine infectious patients.

Plus, a steady series of training exercises shakes out what doesn't work and assists hospitals in tweaking their plans.

However, officials worry about how long Virginia and other states could sustain a massive emergency response. Hospitals have already been through years of spending cuts. Pressure to cut costs has left many with a shortage of bed space and other resources to handle their normal flow of patients. "That's what makes guys like us not sleep at night," says Dr. Joseph P. Ornato, chairman of the department of emergency medicine at Virginia Commonwealth University Health System in Richmond. The overall capacity that hospitals would need "is not going to be there when, God forbid, a huge influenza outbreak hits us. We can do magic for a short period of time, but we cannot sustain it."

A recent study from the Centers for Disease Control and Prevention underscores Ornato's point about the stress already faced by hospital emergency rooms. According to the report released in late September, 40 percent to 50 percent of U.S. hospitals experienced crowded conditions in their emergency departments during 2003 and 2004. In metropolitan regions, nearly two-thirds of emergency rooms faced crowded conditions. And about a third of U.S. hospitals reported that they had to divert patients to other emergency departments because of overcrowding or staff shortages.

In Virginia, VCU is building a new critical-care hospital, and many other hospitals are expanding facilities. In fact, compared with other states, evidence shows that Virginia is doing relatively well when it comes to preparedness. Federal grant money flows through the U.S. Health Resources and Services Administration, a branch of the U.S. Department of Health and Human Services. The money sets certain benchmarks for preparedness in areas such as available beds, decontamination procedures and communications, and Virginia has met or exceeded the standard in most areas, says Bill Berthrong, hospital preparedness coordinator for the Emergency Preparedness and Response Programs at the Virginia Department of Health.

It has done so, Berthrong says, in part by partnering with the Virginia Hospital and Healthcare Association (VHHA), which the state contracted with in 2002 to help manage the federal grant dollars. The association assisted in giving the state a clearer picture of where the needs were, he says. Besides training, grant dollars have been spent on purchasing equipment such as portable beds, building isolation facilities or modifying existing ones. "We wouldn't be as far along as we are without working with them."

Last December, a nationwide study by the Washington-based Trust for America's Health ranked Virginia among the top three states, along with Delaware and South Carolina, on preparedness. It scored well on eight of 10 possible indicators, including the ability to respond to a chemical terrorism threat, providing an infection control professional within 15 minutes on a 24-hour, seven-day-a-week basis and distributing vaccines and antidotes.

Virginia's disaster response is organized on a regional basis. There are six regional health-care coordinating centers that serve as the contact between the scores of smaller hospitals and health-care providers in a region, and officials at the state's Department of Health and Department of Emergency Management. Five of the centers are affiliated with the state's most advanced trauma center hospitals — Inova Fairfax Hospital, University of Virginia Medical Center in Charlottesville, VCU Health System in Richmond, Sentara Norfolk General and Carilion Roanoke Medical Center. The sixth is at the Bristol Regional Medical Center.

Preparing for major public-health emergencies is a confounding process in many ways. Not only does it require anticipating what could happen under a wide range of scenarios, but in many instances it's expected that the scope of a crisis will overwhelm even the most prepared. A major outbreak of influenza, for example, could kill up to 6,300 people in Virginia and require 28,500 hospitalizations. "The reality is, any natural or manmade disaster at a certain scale is going to overwhelm everybody," says Dr. Ornato.

Even so, hospitals have taken steps to prepare. Ornato helped lead a $3.2 million project that provided disaster training to more than 3,000 people during the past two years, from frontline health-care workers to support staff. Plus, besides having the capabilities of a major urban hospital, Ornato's department is staffed with experienced people who deal with thousands of trauma cases a year. "A lot of what people like us do gives us a certain amount of savvy and experience," he says.

At Sentara Williamsburg, integrating disaster planning was made easier because the building is brand new. In fact the location itself is an advantage: It sits 117 feet above sea level in York County but backs up to James City County. As a result, the hospital is connected to both counties' water supplies. Should something happen to one water source, the hospital can switch to the other. And its electrical supply comes through two feeds from two different substations, rather than the more common two feeds from one substation.

The lessons of Hurricane Katrina in the Gulf Coast have influenced West's planning. For one thing, generators in New Orleans were often placed in hospital basements, which flooded. For another, "the diesel fuel was old. As any boat owner knows, diesel fuel can go bad. Hospitals are required to run their generators for 30 minutes a month, but that's not enough to cycle through fuel," he says. At Sentara Williamsburg, the generators sit in soundproof buildings at the back of the property, providing easy access to a tanker truck filled with fuel or back-up generators, in case of an extended power outage. The generators are powered by two 12,000-gallon fuel containers. "We designed our boilers to run on diesel and natural gas. So in the winter, I'll check on whatever energy source is less expensive, and I'll run the boilers on that.

It's a way of using the hospital's money wisely and cycling fuel through the tanks," he says.

In addition, Sentara Williamsburg has a mass decontamination unit in case of a chemical or biological attack. If the need arises, the hospital staff could lock every door in the hospital, directing infected people to the decontamination entrance within the emergency entrance. "Now, those two mass decontamination units are being used as short-stay units, for pediatrics or people on IV therapy or those who are staying less than 24 hours. But in a disaster, we'd convert them," says West. The airflow for those two areas is designed to be separate from the rest of the hospital's air circulation. It's filtered and directed outside, where germs would diffuse rapidly.

Even worst-case scenarios that don't materialize have lessons for hospitals. During the 2001 terrorist attacks at the Pentagon, the medical staff at Inova Health System's Northern Virginia hospitals expected a wave of injured workers. While that didn't happen, the day illustrated the importance of communications, says Don Harris, vice president of government relations for Inova Health System. "Communications was one of the big breakdowns that day," he says.

Another problem that became apparent: Northern Virginia's already clogged roads came to complete gridlock. Should there be an emergency that causes the same kind of anxiety, the region's hospitals would have a tough time distributing or getting supplies via the road network. So helicopter transport of supplies and personnel is now part of the planning there.

Today, the new push from federal officials leading the grant program is to see money spent on developing a coordinated response among the dozens of state, local and private-sector participants that would have a role in a public health emergency. They want more proof that all these different parts can work together. "It's not that we're not acquiring medical supplies and equipment, we still are," says Dr. Mark Dietz, vice president and senior medical director for the VHHA. "Now, more focus is being placed on training, education and exercises so we know how to use the medical supplies and equipment in an emergency situation."

Drills such as a pandemic flu exercise scheduled for late October (after this issue went to press) help hospitals and emergency centers test how systems would work in a real emergency. In the October exercise, the state's six regional health-care coordinating centers (RHCC) were to be activated so they could coordinate the response with each hospital's incident command center. The Northern Virginia center is staffed around the clock now, through a communications link at the trauma center at nearby Inova Fairfax Hospital. "If that were to be overwhelmed, operations move to the Verizon Center and those of us on call would go there to staff the center," Harris says.

But all the dress rehearsals contribute to another problem: they consume some of the resources set aside for real emergencies. How to replace those resources, especially since the federal government's five-year grant program for hospital preparedness is now in its final year, remains a challenge. "Once you put all this stuff in place, it does not last forever," says Steve Ennis, technical adviser for the VHHA on the grant program. "We will always be needing funds."