While hundreds of dialysis facilities were affected as Hurricane Sandy swept through the mid-Atlantic and Northeast region, careful planning and the cooperation of the nephrology community ensured that patients continued to receive care.
Dialysis facilities all have emergency plans in place for patients. Still, “the importance of preparation can not be overstated,” wrote Shaun Collard, leader of DaVita's Emergency Response Team (DaVERT), in an e-mail message.
“These types of weather systems are very unpredictable and can have significant impact to the local area and infrastructure we greatly depend on.”
To monitor the storm's impact and to address the needs of the dialysis community, the Kidney Community Emergency Response (KCER) Coalition held daily conference calls with the End-Stage Renal Disease (ESRD) Networks, the Centers for Medicare & Medicaid Services (CMS), large dialysis organizations, and associations such as the National Kidney Foundation, wrote Joseph Vassalotti, MD, NKF Chief Medical Officer, in an e-mail message.
Throughout the storm, the KCER Coalition provided detailed emergency preparedness information on its website, including phone numbers for patient hotlines, links to information from volunteer and government agencies, lists of open and closed dialysis units, tips on generator safety, and weather reports.
ESRD Networks also worked closely with local officials to make sure dialysis patients received their treatments. For example, IPRO ESRD Network of New York (Network 2) participated in conference calls with the New York City Office of Emergency Management (OEM) and the New York State Department of Health to discuss emergency planning and what information was being relayed to the 130 independent facilities in the area, said Anna Bennett, Community Outreach Coordinator for Network 2, in a phone interview. “One of our employees was in the [NYC OEM] Emergency Operations Center in the days after the hurricane,” she added.
Facilities Brace for Damage
To prepare for Hurricane Sandy, dialysis facilities made sure patients received the details of an emergency renal diet in case they missed a treatment, prescriptions for medicines such as sodium polystyrene sulfonate, copies of recent orders and flow sheets in case they needed care from an alternate provider, and critical patient hotline numbers.
Clinics also informed patients about evacuation procedures in case of an emergency during dialysis treatment and updated their patient contact lists so that if individuals did not show up for treatment, they or their emergency contacts could be reached.
Dialysis facilities heeded evacuation warnings as well.
“If a local community requires everyone to evacuate, we direct all patients to evacuate as well and get dialysis at another location,” said Bill Numbers, Senior Vice President of Operations Support and Incident Commander for Disaster Response and Planning at Fresenius Medical Care North America. “This ensures that they have a safe place to return to each night, such as family members or evacuation centers,” he wrote in an e-mail message.
Dialysis facilities also braced for potential damage from Hurricane Sandy. At some Fresenius locations, staff raised dialysis machines and other equipment off the floor in case of flooding and sandbagged doors that could potentially allow water through, Mr. Numbers said.
The dialysis provider prepared its permanent generators at locations where these were installed, prepositioned portable generators at large dialysis facilities, and provided centers with fuel.
“Generators were hard to come by in the Northeast,” Mr. Collard noted. Just a few days before Sandy made landfall, DaVERT volunteers from the Southeast region drove across several states to deliver generators to areas expected to be hardest hit. Other facilities rented generators from local businesses, and DaVita positioned fuel trucks to ensure gas supply.
To further prepare, “dialysis clinics provided alternate treatment schedules both in anticipation of the storm and after the storm so that patients would not need to access care during the peak of the storm,” Dr. Vassalotti said.
For example, Dialysis Clinic Inc. (DCI) facilities in Westchester, NY, opened on Sunday, Oct. 28, to treat patients originally scheduled for Monday dialysis. In turn, patients scheduled for Tuesday, the day the storm was expected to hit, came in on Monday, enabling centers to close when Hurricane Sandy was at its worst, wrote Karen Hansen, DCI Corporate Administrator, in an e-mail message.
American Renal Associates (ARA) clinics in the affected areas were open for longer hours on Monday and closed on Tuesday so that employees and staff did not have to worry about traveling during the storm, wrote Shari Cousins RN, CNN, Regional Vice President of Operations, in an e-mail message. “Some treatments were cut to three hours to accommodate all patients having treatments per order of [the] nephrologist,” she said.
In addition to being open the Sunday before the storm, Fresenius locations opened the Sunday following the hurricane so patients could make up treatments they may have missed during the week, Mr. Numbers said. Overall, Hurricane Sandy and the subsequent snowstorm in the Appalachian Mountains resulted in 230 Fresenius dialysis facilities having to change patient schedules.
DSI Renal's emergency response group closely monitored the track and progress of Hurricane Sandy and identified nine clinics likely to be affected by the storm.
“The clinical teams at these facilities worked tirelessly to prepare and provide treatments for as many patients as possible over the weekend before having to take cover themselves,” wrote Johnie L. Flotte, RN, Vice President of Education & Quality for DSI Renal, in an e-mail message.
“Our efforts to advance appointments into the weekend for patients scheduled to receive dialysis on Monday and Tuesday allowed us to avoid any missed treatments.”
‘Everyone Came Together’
While some dialysis facilities in the direct path of Sandy closed due to flooding and power outages, ESRD Networks and dialysis providers worked together to make sure that all patients were accommodated and able to receive treatment, Dr. Vassalotti said.
In New Jersey, “any facility that was forced to close due to generator failure, water quality concerns, or flooding ensured that all their patients were accounted for and treatments were arranged at other providers,” said Joan Wickizer, LSW, NSW-C, Patient Services Coordinator at Quality Insights Renal Network 3. Overall, 1,161 patients in Network 3 were displaced during the course of the storm, and eight were unaccounted for initially. All patients were located by Nov. 6.
While New Jersey has a state regulation requiring dialysis facilities to have an on-site backup generator to contend with power outages, many of these broke down, requiring patient transfers to other dialysis centers so care wasn't interrupted, Ms. Wickizer said.
Flooding and resultant water quality concerns closed the outpatient dialysis unit at AtlantiCare Regional Medical Center, Atlantic City Campus, for three days. These patients were treated at Shore Medical Center and Liberty Dialysis in Hammonton, NJ. Additionally, RCG Atlantic City Dialysis Center closed for several days, and patients were treated at Fresenius facilities in the region.
“We treated many patients [who] were not Fresenius Medical Care patients,” Mr. Numbers noted. “In many areas, patients came to our clinics even if we did not have any admission paperwork or health care information. We have procedures that allow us to treat these patients safely.”
American Renal Associates also took about 10 patients into its Woodland Park, NJ, unit from other area facilities that had shut down, Ms. Cousins noted.
One Fresenius facility in Hoboken, NJ, closed due to flooding, and repairs will not be completed for months, Ms. Wickizer said. In the meantime, patients are being treated at other Fresenius facilities.
Lost power and facility closures, as well as transportation problems, affected about 13,000 Network 2 dialysis patients, according to Ms. Bennett. Seven Network 2 dialysis centers throughout the New York City area were catastrophically damaged and are still not open. Some need to be completely rebuilt, and the timeline for reopening could be up to six months, she said.
About 3,000 individuals in Network 2 were displaced, and more than 600 were unaccounted for after the storm. Locating them all took until Nov. 28, initially because of downed cable lines and cell phone towers, and later because of some patients relocating to stay with friends or family or to seek care elsewhere, Ms. Bennett explained.
One of the major priorities on the first day of the storm was to address the displacement of 600 patients at four dialysis centers in Lower Manhattan, said Susan Caponi, Executive Director of Network 2. “We worked with the Department of Health, the Office of Emergency Management, and large dialysis organizations Fresenius and DaVita to get a generator so patients could be treated at one of the four locations.”
“As a dialysis community, everyone came together,” Ms. Bennett added. “When placing patients, it didn't matter who the provider was; it was just who could offer dialysis.” In the best-case scenario, transferring patient care was seamless, she said. In the worst-case scenario, the patient turned up in the emergency department, was treated, and then was placed in a dialysis facility.
Shortly after the storm made landfall, 10 Network 2 dialysis centers began operating on generator power. One DaVita facility in Garden City, NY, had a generator delivered by DaVERT volunteers just three hours before opening.
“This truck pulled up with a ‘DaVita Emergency Services’ sticker on the side, and four guys got out with DaVita jackets,” said Marie Ginobbi, a DaVita RN Facility Administrator. “I was so relieved to see them, that moment took my breath away. My team, our patients and families are forever grateful.”
Farther north, the DCI Clinic in Hawthorne, NY, lost power for eight days, Ms. Hansen said, adding that this clinic was in a medical office building and did not have a backup emergency generator. Eighty-four patients were assigned to one of three other DCI clinics in Westchester County for treatment until the Hawthorne clinic reopened Nov. 7. Some treatment times were shortened to accommodate all of the patients at the various locations. Three patients couldn't be reached because phone service was down in the nursing homes where they lived, so DCI contacted their family members to make treatment arrangements, Ms. Hansen added.
Due to the large nature of the storm, trying to pinpoint the number of power outages, closures, and displacements that occurred on particular days can still be challenging for providers.
“At one point we had more than 100 clinics closed in one day,” Mr. Collard wrote, adding that many of the affected patients had been dialyzed on other days in preparation for the storm or rerouted to other clinics for treatment.
DaVita Guest Services assisted centers with contacting every patient and ensuring they were receiving dialysis, if not with DaVita, then with another center or hospital, Mr. Collard said. “It's safe to say that hundreds of patients were either rescheduled or rerouted to receive their care,” he added. All DaVita patients were accounted for as of Nov. 9.
Gas Shortage Challenging
Damage from Hurricane Sandy made obtaining gas for facility generators, dialysis clinic staff, and transportation providers challenging at times, Dr. Vassalotti said.
Gas shortages required some Network 3 facilities to locate alternate sources of fuel for their generators because their contracted providers were left damaged by the storm, Ms. Wickizer said. The Network connected dialysis providers with fuel services so patient treatments weren't interrupted. The Department of Health also arranged for state and federal assistance to be available as needed for fuel delivery, she said.
Despite the gas shortage, Network 3 wasn't made aware of any major problems with patient transportation during the storm. Fortunately, the county Offices of Emergency Management were helpful in assisting dialysis patients with alternate transportation if needed, Ms. Wickizer said.
Staff transportation was another matter. One of the biggest challenges for ARA employees in New Jersey “was the inability to obtain gasoline for their vehicles to drive back and forth to work,” Ms. Cousins said. The provider's medical director called the New Jersey Governor's Office for advice, while Ms. Cousins contacted ESRD Network 3 for assistance. Finally, the Monday following the hurricane, the local clinic manager in Woodland Park, NJ, spoke with the town's mayor and police chief to arrange a police escort of staff to a gas station to break the hour or more line so their cars could be refueled.
The gas shortage was also a major concern of Network 2 staff, Ms. Caponi said. However, when the shortage impacted patients, facilities helped arrange for alternate transportation. Additionally, large dialysis organizations collaborated to share their gas supply so employees could get to work and generators could run, she said.
For example, DaVita provided approximately 15,000 gallons of diesel for generators to keep its clinics running, as well as 10,000 gallons of unleaded gasoline for cars so that those providing care to patients could continue to do so. Once roadways were safe to travel, DaVita contracted fuel trucks and created a delivery system throughout the New York City metropolitan area, allowing employees to get fuel without having to travel far.
Fresenius provided 40,000 gallons of gasoline to its employees so they could get to work.
“We set up five gas deposit locations, all protected by armed guards,” Mr. Numbers said.
No Power at Home
Another problem for dialysis facilities was that staff members experienced power outages at home.
Hundreds of Fresenius employees were without power for an extended period of time. In response, the dialysis provider distributed 450 home generators to clinic staff members and provided food, water, and other necessities to all employees who needed assistance. Some employees who had flooded homes were offered hotel rooms or RVs to stay in until other arrangements could be made, Mr. Numbers said.
DaVita also provided generators to many of its own, some who had been without power for two weeks, so they could stay in their homes, closer to the dialysis centers where they worked, Mr. Collard said.
Once power was restored, there were those who opened their homes to others in turn. DaVita RN Facility Administrator Marie Ginobbi let a driver from South Carolina who was delivering gasoline to the area stay with her family, who had previously been without power, in Garden City, NY.
Many of the ARA New Jersey clinic staff did not have power at their homes; however, this didn't interfere with their ability to provide patient care.
“Some days were more stressful than others, but everyone showed up to work,” Ms. Cousins said. “They endured and showed for work each and every day to care for their patients.”