From Katrina to Pandemic-Business as Unusual: Adaptation of a Proven Response Model

As Hurricane Katrina approached the coasts of Louisiana, Mississippi and Alabama in September 2005, no one expected it would affect the lives of residents more than 500 miles away. Located in north central Texas, Tarrant County is an urban county housing Fort Worth and smaller communities. It encompasses approximately 860 square miles with a population of approximately 1.6 million people.

More than 4,500 evacuees were transported to Tarrant County during the four-day evacuation when the Federal Emergency Management Agency (FEMA) activated the Emergency Operations plan in six surrounding states to assist in evacuation of Gulf Coast residents. Additionally, 10,000 others came to the area prior to the officially declared evacuation for protection from the storm.

The JPS Health Network (JPS) is an integrated county healthcare organization comprised of a 459-bed hospital, 24 community health centers, and 10 pharmacies. JPS was called upon to provide needed medical care to evacuees as the lead healthcare agency for Tarrant County. Throughout its history, the JPS mission has been to serve as the community safety net health system and provide the best possible care under the duress of any disastrous event. However, this situation was unique. Previous emergency responses focused on hospital based responses for victims of traditional disasters such as tornadoes, local floods, multiple vehicle crashes, and major chemical spills. The Katrina disaster, on the other hand, required a new type of response designed to focus on coordination of acute and chronic healthcare resources within a multi-staged response. Tarrant County was required to coordinate the issue of surge capacity, which is the ability to manage a sudden, unexpected increase in patient volume that would otherwise severely challenge or exceed the current capacity of the healthcare system.¹

JPS Response to the Influx of Evacuees into Tarrant County

JPS developed a patient-centric catastrophic tactical response model. The development, approach, and implementation of the model are described in the following five-day event journal.

Thursday, Sept. 1, 2005 

JPS requested by Emergency Operations Center (EOC) to provide medical care for the initial evacuee shelter. Physicians, residents and nurses provide initial medical triage, care and medications at the initial shelter for 200 people. As a second shelter opens (with a capacity of 200 people), medical assistance shifts to centralized-clinic approach to protect hospital resources and avoid unnecessary crowding.

Friday, Sept. 2, 2005 

In the early morning, five additional C-130 transport aircrafts arrive and a third shelter opens (with a capacity of 250 people). The EOC develops a receiving center approach, a central location where all evacuees are received into the community, medically triaged, registered, and assigned to shelters. Buses arrive and more shelters are opened. The JPS team meets each bus at the receiving center and triages evacuees for severe illness and medical conditions. Those needing care are transported two blocks to the health center or to the emergency room if appropriate.

Saturday, Sept. 3, 2005 

The evacuation becomes a media focus with emphasis on donations. As buses of evacuees continue to arrive, so do donations of clothing, personalcare items, and food. Buses continue arriving and the number of shelters grows to 18, housing approximately 2,700 people.

Sunday, Sept. 4, 2005 

Busloads of people continue to arrive. The receiving center process works well to coordinate resources. Twenty-five county shelters are operational with additional shelters opening in large churches.

Monday, Sept. 5, 2005

The number of evacuee buses arriving begins to decrease. Shelters are full (4,500 people) in Tarrant County. Additional evacuees arriving in cars are housed in hotels, motels, and with family/friends living in the area.

Throughout the five-day event, JPS developed and refined a series of outcome indicators to measure and validate the effectiveness of its tactical response program as it evolved. The following outcomes were used to measure the disaster response:

• Cost per patient 
• Total costs 
• Reimbursements 
• Compliance of evacuees in using the health network as measured by keeping scheduled follow-up clinic visits 
• Medication costs 
• Incidence of new onset infectious disease outbreaks in the evacuee population

Similarities in the Hurricane Surge Response to Mass Casualty Response

Hurricane Katrina disaster conditions required a new, sustained, phased type of surge response with decentralized resource management. A pandemic event or any catastrophic outbreak of infectious disease will likely have an intense and similar affect on the availability and delivery of healthcare services.

In responding to a pandemic incident, the approach of coordinating large groups of individuals while protecting hospital resources as was utilized in the hurricane surge response could be an effective means of controlling outbreaks and cross-contamination. This technique ensures proper allocation of limited resources and facilitates allocation of resources in a just-in-time manner that places the resource where they are needed, when they are needed and in the manner needed. This response is also centralized away from the hospital campus in a clinic format, thus protecting the hospital resources for critically ill people.

Influenza is a highly contagious viral disease. An influenza pandemic is a worldwide outbreak of disease that occurs when a new or novel virus emerges in the human population, causes serious illness, and spreads easily from person to person. During the past 400 years there have been 12 influenza pandemics, three of them during the last century.2 The highly pathogenic avian H5N1 virus, which has infected birds across eastern Asia and other countries, is raising major concerns about its potential to cause a pandemic in humans.

In the absence of vaccines or natural immunity to a virus, the available health strategies are limited to the rapid identification of infected person, mass distribution of antiviral medications for treatment and prophylaxis, and activation of control measures in preventing transmission in respiratory-illness outbreaks. These measures include:

• Community surveillance 
• Detection and isolation of cases 
• Identification and monitoring of contacts
• Adherence to infection control precautions
• Measures to restrict movement of potentially infected person²

Since the Katrina disaster, JPS has initiated discussions with the Public Health Department and other community service entities in the region regarding the surge response and the application of aspects of this strategy to the planning for public health response to possible pandemic influenza and/or other similar bioterrorism events.

Environmental and Healthcare Delivery System Adaptations Required in Handling a Disaster Surge

The Centers for Disease Control and Prevention (CDC) has developed a community migration framework that should be initiated early and maintained consistently during an epidemic wave including:³

• Isolation may occur in the home or healthcare setting, depending on an individuals illness and/or the capacity of the healthcare infrastructure 
• Voluntary home quarantine of members of households with confirmed or probably influenza
• Dismissal of students from school systems and the possible closing of shopping malls and movie theaters 
• Use of social distancing measures to reduce contact between adults in the community 

The Joint Commission has published criteria from its Management of the Environment of Care (EC) standards to ensure hospitals provide a safe, functional, supportive and effective environment for patients, staff members, and other individuals in the hospital.

In accordance with Standard EC 4.10, JPS addressed emergency management through the treatment of more than 1,700 evacuees, filled more than 4,000 prescriptions, and staffed more than 250 people during the Hurricane Katrina response. The critically ill patients were transferred directly to the hospital in meeting Standard EC. 4.10, element of performance (EP) 13.4 The plan provided processes for establishing alternate care sites that had the capabilities to meet the needs of patients when the environment could not support adequate care, treatment, and services. The non-critically ill were moved to shelters established at community centers. Physicians and nurses from JPS provided initial medical care and medication at the shelter while the hospital itself, already filled with its own patients, continued to operate as usual. Despite the numbers of evacuees, JPS admitted only 30 evacuees to John Peter Smith Hospital (the main hospital facility).

Element of performance (EP) 15 calls for the plan to provide processes for cooperative planning with healthcare organizations that together provide services to a contiguous geographic area to facilitate the timely sharing of information (JCAHO 2007). The triage center provided the essential elements of the command structure and control center for a centralized response methodology. This set-up also allowed for resources and assets to be shared during the response.

Delineation of roles and responsibilities (EP) 19 were clearly defined in the surge response with the implementation of the JPS disaster response plan. This plan, utilizing the NIMS criteria, was continually adapted during the sustained six day surge response.5 The response plan utilized the divisions of response. Individuals assigned in leadership roles maintained the role through out the five-day response, providing continuity with decision making and coordination. This structure was supported as part of the Tarrant County Emergency Response in coordination with FEMA. 

Trudy Sanders, MA, RN, CNAA, BC, is senior director/critical care and nursing administration; Adonna Lowe, MA, RN, CHE, is president/chief nursing officer; and Glenn Raup, PhD (c), RN, is senior director/emergency and urgent care services at the JPS Health Network.