Published in the November 2017 issue of Today’s Hospitalist
WHEN DEAN DALILI, MD, MHCM, senior vice president and group medical director for Schumacher Clinical Partners, helped engineer the evacuation of a hospital in central Florida last year during Hurricane Matthew, he took comfort in the belief that another hurricane wouldn’t make landfall in that state for 10 or 20 years.
But then the 2017 hurricane season arrived. Dr. Dalili, who lives in Houston, first rode out Hurricane Harvey in his home, then helped lead the response of hospitalist groups at five separate Florida hospitals during Hurricane Irma less than two weeks later. To visit those programs, he flew into Orlando on the third flight that landed there after the airport re-opened.
“Schumacher Clinical Partners is in 400 hospitals, and a large number of them are in Texas, Louisiana, Florida, South or North Carolina, and Mississippi,” says Dr. Dalili. “A tremendous amount of our business is in an area that is perpetually at risk.”
“We had more volunteers than we needed.”
~ Rohit Uppal, MD
Charles Jaynes, MD, senior director of medical operations for Ob Hospitalist Group, now lives in Austin. But Dr. Jaynes practiced outside Houston for more than 30 years, and he now oversees OB hospitalist programs in several states, including 14 hospitals in Texas. One is in Corpus Christi, while four are in the Houston area.
“This was by no means our first dance with a hurricane,” says Dr. Jaynes, who notes that building codes for hospitals in Texas have become much more stringent after hospitals were devastated in previous hurricanes and tropical storms. Given the fact that Harvey was “a biblical event with 52 inches of rain, which you simply can’t defend against,” Dr. Jaynes says, “I think Houston hospitals had the best-orchestrated disaster plan I’ve seen to date.”
But that doesn’t mean physicians’ experiences in both Houston and Florida weren’t immensely stressful. While long-time residents of both locales say they’d learned a lot from previous hurricanes, Harvey—which didn’t provide much advanced notice—and Irma, where people had much more warning, still delivered key lessons in how to prepare for and work through a natural disaster.
Identifying a storm team
Along with two other medical directors, Dr. Jaynes oversees about 35 OB hospitalist programs in the central U.S. “It’s my routine the first week in May to pick up the phone and call all my team leads along the Gulf Coast,” he says. “I tell them, ‘Please get out your hurricane preparedness and disaster plan for your hospital, read it through, discuss it with your administration, and think about it with your team so you’re prepared.’ ”
As Harvey barreled down, Dr. Jaynes had his corporate office send him the cell phone numbers for all the programs’ hospitalists there. His company also contacted large obstetric practices in Houston and agreed to cover their patients.
The company also worked with OB practices in Austin to assume care for pregnant patients who’d evacuated there from Houston and south Texas. Meanwhile, pregnant patients with complications would remain in Houston, sheltering in hospitals during the storm, while each program decided which two OB hospitalists—each working a 12-hour shift to be able to relieve the other—would staff the storm.
“We didn’t have enough hours or staff to dialyze all the patients who came to the ED, so we had to admit them.”
~ Raj Mahadevan, MD
Cape Coral Hospitalists
“It tends to be hospitalists who don’t have small or impaired children at home,” Dr. Jaynes points out.
According to Dr. Dalili, it’s critical to identify the storm-coverage team as early as possible to give those doctors time to get their homes ready and to evacuate their families, if they’re going to do so. His company also did daily hurricane planning calls with regional and program directors from three days before each storm to three days after.
Dr. Jaynes’ company encouraged its senior leadership to contact each hospitalist to check in, an innovation begun in Houston that was adopted a week or two later by the company’s medical leadership in Florida. But “that was one of the suggestions we got from the Florida hospitalists,” he points out. “They were so busy, they didn’t have time to take all the phone calls coming in from different people in the organization checking on them.” As a result, the decision was made to have only one person a day check in with individual doctors.
A call for volunteers
With massive flooding in Houston, Dr. Jaynes says the hospitalists in two OB hospitalist programs had to stay in-house for five days before they could be relieved. One problem: One doctor had brought only four days’ worth of clothes, and all her scrubs were bloody. (The hospital’s laundry staff couldn’t get to work.) Fortunately, a physician who lived nearby and was able to travel back and forth to the hospital offered her home to her colleague to do laundry.
Rohit Uppal, MD, president of the hospital medicine division for TeamHealth, says the company has “a handful of programs in the Houston area” and dozens in Florida that were affected by the storms. In Houston, being able to relieve the physicians who covered Harvey initially likewise became a huge problem, with hospitalist teams spending up to three days in hospitals surrounded by floodwater. Relief physicians weren’t able to leave their homes and get to their hospitals.
Fortunately, says Dr. Uppal, Texas temporarily lifted state licensing requirements, and TeamHealth’s size and resources— approximately 20,000 affiliated physicians and advanced practice clinicians serving in 3,300 facilities nationwide—were put to good use. “Our credentialing and scheduling departments worked around the clock to bring in clinicians from around the country, while our travel department helped them get from city to city.” The company used its corporate jet in Knoxville to transport doctors to Dallas, some of whom were then helicoptered directly to Houston hospitals.
The company also tapped into its own internal locums division, D&Y. “We were able to call upon our clinicians and nonclinicians to come and volunteer, and we had a remarkable response,” he says. “We had more volunteers than we needed.”
Covering two hurricanes
One hospitalist who answered that call was Ariel Caplan, DO, who works at Memorial Regional Hospital in Hollywood, Fla. When the TeamHealth e-mail went out asking for volunteers, Dr. Caplan responded. Her Florida colleagues quickly offered to cover her shifts.
Dr. Caplan, who was part of the second wave of volunteers to provide relief in Houston hospitals, was able to fly to Houston and drive to a hospital within the Memorial Hermann Health System where she pulled three shifts. She arrived the Friday after Harvey hit, when much of Houston was still flooded, and flew back to Florida the following Monday. Sept. 4. She slept one night on a cot in the hospital, then was put up in a hotel.
“I’d never volunteered before, and it was something I always wanted to do,” she says. “As soon as I got the e-mail, I felt compelled to go, knowing that that could have been us.”
Less than a week later, it was her program in Florida that needed some relief. During Irma, Dr. Caplan was one of the hospitalists covering the storm, arriving for her shift at 6:45 a.m. on Saturday, Sept. 9, and staying until the following Monday.
A dialysis crisis
In flooded Houston, says Dr. Uppal, patients’ lack of access to regular dialysis became “an overwhelming crisis in hospitals and emergency rooms. We were able to partner with major dialysis centers throughout Houston to find alternate routes and have those patients dialyzed.”
Because Florida had more warning before Irma, he adds, TeamHealth could make those arrangements before the storm hit, “so we did not find ourselves reaching that crisis stage.”
But according to Raj Mahadevan, MD, lack of access to dialysis remained a major problem in Florida in the days after Irma. Dr. Mahadevan is the owner of Cape Coral Hospitalists, a local hospitalist practice serving six hospitals around Naples, which sustained a direct hit.
“We didn’t have enough hours or staff to dialyze all the patients who came to the ED, so we had to admit them,” he points out. Another big problem: Trying to discharge patients who needed home oxygen when home supplies couldn’t be delivered, so “we could not send them home.” One of his recommendations going forward is to have shelters administer oxygen to patients so they don’t need to be hospitalized.
As Dr. Mahadevan points out, Irma hit during the height of Florida’s off-season, when doctors are encouraged to take time off . With EMS suspended during the actual storm and a curfew imposed, the hospitals were fairly quiet. As with many Florida clinicians, his family was able to ride out the storm in one of the hospitals with him.
“I had my four children in one room with juices and popcorn, watching trees go past the window,” he says. “They had box seats for the hurricane.”
But as Dr. Mahadevan puts it, Sept. 11—the day after Irma hit, when EMS was restored and patients could get to hospitals—”was a true disaster for us in terms of patients.” By then, relief hospitalists had come in, but those who’d stayed the storm stayed to try to keep up with the census. Across the six hospitals, the hospitalist census two days before Irma was 265. “Two days after,” he points out, “it was 440. It was mainly patients with chronic conditions who could not go home because they were frail and there were absolutely no services.” Like the rest of his group, Dr. Mahadevan spent the days after the storm seeing 30 or more patients a day.
Some of the hospitals where group members work were on generators for emergency power for days, Dr. Mahadevan says, while communication systems went down. To reach hospitalists, the ED physicians relied on doctors’ personal cell phones.
What helped the hospitalist programs get back to normal within a week was that none of the six hospitals was evacuated.
“That would have really stretched us, because physicians would have had to move to receiving facilities, with emergency privileges,” he says. “Instead, each facility was able to take care of its own.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
• Prepare to lose power. Dean Dalili, MD, MHCM, who lives in Houston, is senior vice president and group medical director for Schumacher Clinical Partners. He oversaw storm preparations for several hospitalist groups on Florida’s east coast. His advice: Before a storm hits, think through how you identify patients, bill, create rounding lists and communicate with nurses.
“Then think about how to do all that with only paper, and print all those forms in advance,” says Dr. Dalili. Raj Mahadevan, MD, the owner of a local hospitalist practice serving six hospitals around Naples, Fla., notes that the EHR in at least one hospital where the group works went down.
“We had to go back to ancient medicine and remember how to handwrite an H&P without being able to dictate it,” he says. “We had to go look for pens, which we haven’t used in years.”
Another problem with lost power: Gas pumps run on electricity, and dwindling gas in cars becomes a problem. Dr. Mahadevan made sure both his family cars were gassed up, and he was able to give some hospitalists a ride. But going forward, he recommends that hospitals in areas prone to storms have a van that could be used to ferry staff members home and back.
• Promote self-sufficiency. Doctors covering storms need to bring seven days’ worth of clothes, personal medications and toiletries, as well as pillows, nonperishable food and an air mattress if the hospital can’t provide cots or beds. In Texas, Charles Jaynes, MD, senior director of medical operations for Ob Hospitalist Group, also recommends that doctors bring a headlamp, a hand-cranked radio and flashlight that don’t run on batteries, remote phone chargers, and cash.
• Plan for a post-storm surge. Chances are nursing homes won’t be able to accept patients you want to discharge, dialysis centers may be closed and primary care physicians may have evacuated. “For hospitals in Florida,” says Dr. Dalili, “the day after a storm is the busiest day of the year,” with a census running at least 20% higher than normal.
• Manage fatigue. According to Dr. Dalili, the clinicians coming in to relieve those who staff the storm are often as exhausted as the people they’re relieving. That’s because they’ve been at home clearing debris.
To guard against that, leaders must stress the need for sleep, both for those working in the hospital and those at home. During Irma and its immediate aftermath, Dr. Dalili made a point of asking every program leader how much sleep he or she received the night before.
“It was important for me that doctors were sleeping, and it’s important for leaders to model that for their team,” he says. “We need to role model how important it is to take care of ourselves.”
• Manage anxiety. During a storm, you can bet that every TV in the hospital will be tuned to storm coverage and nothing but. “That may be fi ne for consumption in Utah,” says Dr. Dalili, “but the people actually in the eyewall or tornado area can become overwhelmed with fear.”
A storm, he adds, “is an emotional event as much as a physical one. You can manage people’s emotions by being as prepared as you can be and by talking prospectively about stress, the importance of teamwork and taking care of yourself. Those are critical management skills.”
• Leaders need to lead. During a storm and its aftermath, program directors need time to check in with group members and administrators. For program directors, “if you can, don’t take an equal share of patients,” Dr. Dalili suggests. “Your primary role as a director is to communicate, and you have to free yourself up for management meetings.”