Brands, Chad K. MD; Hernandez, Raquel G. MD, MPH; Stenberg, Arnold CPA; Carnes, Gary MBA; Ellen, Jonathan MD; Epstein, Michael MD; Strouse, Timothy BA
* Disaster preparedness requires visionary yet pragmatic planning when new hospitals are constructed. Considering institutional lessons learned is critical to the design phase.
* Learning from external institutional experiences allows leaders to adapt the design and construction of new hospitals for optimal disaster functionality.
* We introduce the construct of complete self-sufficiency planning in hospital design, outline its components, and propose use of complete self-sufficiency planning as a model for designing hospitals to function optimally in disasters.
The United States has sustained a historic number of hurricane-related disasters during the last decade.1 The economic costs of these disasters are tremendous,2 and the social-emotional repercussions of being unprepared for these events are immeasurable. The need for optimally prepared healthcare systems and tertiary/quaternary care academic medical centers in the event of a disaster is well documented,3 with events such as Hurricane Katrina illustrating the major gap in disaster preparedness for at-risk medical institutions.4–9 The state of Florida has experienced twice as many category 5 hurricanes than any other Gulf Coast state during the past century.1 This region’s vulnerability to severe storms reminds effective leaders that optimal preparation for disasters is a necessary best strategy. Recent disasters underscore the enormous toll a similar event could have on an entire geographic region.
When the medical and administrative leaders of All Children’s Hospital Johns Hopkins Medicine (ACH JHM) set out to design and build a new freestanding children’s hospital (completed in 2010), they determined that disaster preparedness was imperative. They considered multiple contingencies and worst-case scenarios in planning for potential disasters with the services of a fully functional hospital. A comprehensive vulnerability assessment led to the development of the construct we have termed complete self-sufficiency planning (CSSP), useful for future disasters, either natural or manmade. This article outlines key steps in disaster planning, including the components of CSSP that should be considered in designing and building new hospitals.
Disaster preparedness requires visionary and pragmatic planning when new hospitals are constructed, and considering institutional lessons learned is critical to the design phase. Early in the design phase of the new hospital, unit leaders identified potential emergencies and the direct and indirect effects that these incidents may have on the ability of the hospital to operate at its highest capacity. Following additional study and deliberation, a commitment was made by the executive leadership to prepare for and finance “what if” scenarios in the design phase. The executive administrative team presented this disaster planning approach for discussion and approval to the ACH JHM board of trustees. The board relied on this framework during all of the discussions involved in finalizing the design. For example, moving the major mechanical equipment to hurricane-protected space above flood stage was estimated to add $2.3 million, but it was considered to be one of the highest priorities.
The vulnerabilities of ACH JHM were particularly evident during the 2004 hurricane season, when southwest Florida was battered by Hurricanes Charley (category 3), Frances (category 2), and Jeanne (category 3).1 This series of hurricanes allowed us the opportunity for specific lessons learned in disaster preparation. These issues included shortage of diesel fuel, challenges in sustainability of operations resulting from the lack of emergency power, vulnerability of the mechanical equipment below flood stage, poor exterior window protection from high-velocity projectiles, and the critical need for communication and public services.
With the costs of these hurricanes exceeding $33 billion,2 this period promoted heightened awareness of the disaster readiness of ACH JHM and indicated that optimal functionality in disasters would require a multimillion-dollar upgrade. The lessons learned, in combination with data from our previous 3 years of assessments, using the American Hospital Association’s Hazard Vulnerability Analysis Tool,10 drove the planning to optimize our new hospital’s functionality during hurricanes and other disasters.
Learning from external institutional experiences allows leaders to adapt the design and construction of new hospitals for optimal disaster functionality; our operations team visited New Orleans following Hurricane Katrina in August 2005. The lessons learned by medical centers and healthcare professionals during and after this disaster are well documented. The challenges faced were limited emergency communications,8 lack of security,11 flooding and subsequent mechanical equipment failure, and great difficulty evacuating patients out of affected hospitals.4–6 Temperature control also was a major and unexpected limitation because air conditioners could not be powered for patient care.8,9 As a result, several hospitals found it necessary to evacuate several days after the massive hurricane.
Hospitals were unable to use their helipads because of the size and weight of the military helicopters that were readily available for transport. Our visit to New Orleans proved to be highly informative and led the leadership team to consider the benefits of redesigning our rooftop helipad to allow ready use by military helicopters. A $1 million Health Resources and Services Administration grant was obtained for this endeavor.
The engagement of all key stakeholders and decision makers regarding guiding principles can ensure the successful design and building of a hospital that is prepared for all disaster contingencies. A multidisciplinary team of stakeholders who were engaged in the earliest stages of planning for design promoted our success in achieving CSSP. The team consisted of community representatives, families, nursing staff, physicians, and hospital unit leaders who worked through implementing the vision of and expectations for design and clinical capabilities.
Critical elements of the CSSP concept included needs to maximize communication, transportation and readily-available access to supplies postdisaster. The board of trustees created a construction task force, which was actively engaged in each stage of the design, evaluated options presented by management and the architects, and developed recommendations for presentation to the full board of trustees. Some recommendations presented challenges. For example, the recommendation of a central energy plant (CEP) required additional analysis to determine the number and capacity of generators and chillers, the types of fuel sources, and the equipment necessary to create a potable water supply. Many such critical barriers were encountered by Florida medical institutions following the disastrous hurricane seasons of 2004 and 2005.
Similar evaluations were undertaken for all major aspects of disaster preparedness, including structural engineering of the building and construction of a hardened space for mechanicals placed above flood stage and removed from the roof. Adhering to the guiding principle of optimal functionality during disasters ensured that all of the component processes led to the design and building of a completely self-sufficient facility.
The construct of complete CSSP that was used to design and build a hospital that could function optimally in disasters is outlined below. We propose CSSP components as the best pragmatic practices in disaster preparedness when designing new hospital facilities. The critical core elements of CSSP are as follows:
* Generating power that will enable the operating systems of the hospital to function normally
* Protecting the structural integrity of the building and safeguarding electrical and mechanical equipment by placing these components into the heart of the building, away from hazards
* Ensuring that vital day-to-day functions of the hospital will not fail (air temperature and quality, water supply, plumbing, sewage disposal)
* Storing essential supplies with which to operate the hospital for 1 month
* Creating failure-proof transportation and security systems to provide for effective and safe transport of patients
* Upsizing the capacity of the hospital to accommodate regional demands and needs
* Building redundancy into all systems
* Preparing for disasters that have occurred elsewhere but not necessarily locally
The categories air quality, building protection, communication systems, disaster locker, electrical power, electronic medical record redundancy, emergency response, mechanical equipment, security, transportation, and water supply and treatment highlight areas in the new ACH JHM that reflect our CSSP planning paradigm. The vision reflects the ideal that each component would enhance the function of the overall hospital during a disaster. (A short video highlighting the design features of the hospital is available at http://www.allkids.org/body.cfm?id=737.)
All patient areas function with 100% HEPA filtration. In addition, by a simple flip of the switch, we designed a dedicated unit (with 28 patient rooms) that is capable of immediate conversion to 100% negative pressure. These rooms will be in high demand for immunosuppressed patients during the hospital upsizing scenario we anticipated should a disaster occur. This design enables ACH JHM to address a bioterrorism threat. In the event of fire, air quality will be preserved by the presence of a smoke-evacuation system. Including positive pressure stairwells and building smoke-tight corridors enables ACH JHM to protect patients adequately from airborne pathogens and reduce the risk of smoke inhalation.
To avoid damage from projectiles and airborne debris during disasters, windows up to the sixth story were reinforced for added protection, and all hospital windows are rated for hurricane winds up to 130 mph. Because of the lessons we learned from the 2004 and 2005 hurricane seasons, the windows at ACH JHM were intentionally structured to remain closed to promote the utmost stability during structural impacts.
Multiple redundancies were built into ACH JHM to avoid the failures in communication that have been noted in recent disasters. Antennae were distributed throughout the hospital, medical office building, and CEP and connected to a repeater for greater distance coverage. We also provided a distributed antenna system for our staff, police, and fire and rescue personnel to enable regular communication. As a result, cellular telephones and radio systems can function at full capacity at all times. We also added short-wave radios (ham radios), two-way radios, and multiple satellite telephones at CEP as backup for emergency communication.
Our stakeholder teams created a stockpile of equipment that is needed immediately in disasters and that pragmatically implements CSSP (Table). Creating the disaster locker cost $25,000.
Table Disaster locke...Image Tools
Completely redundant (100%) power in the hospital will be provided by six 2000-horsepower generators capable of delivering power for all systems for a duration of 21 days (Fig. 1). Our CEP will provide energy to every outlet in the hospital, not solely the “red plug” life and safety emergency outlets that are typically used in disasters. A unique automated power-switching mechanism will be used to enable emergency power transfer. This specific power redundancy mechanism was included to avoid component system failure in the event of power outages. With these methods of redundant power generation, events such as stairwells remaining unlit or storage freezers being incapacitated will be avoided. Four underground diesel fuel tanks located approximately 100 ft from the CEP above flood level will ensure additional power for the functioning of the hospital. These tanks are sealed against water penetration. We also created an agreement with the city of St Petersburg that facilitates the refueling of these tanks; however, we maintain 150,000 gal of fuel, enough to run our generators and boiler for >21 days at 70% capacity. Although the concept of a CEP has long existed,12 we are unaware of any other institutions that have moved toward complete redundancy in generating 100% of the power for normal operations.
Electronic Medical Record Redundancy
Patient information will be protected during a time of disaster. An independent building separate from the main hospital will serve as the core information technology protective space. A remote hosting process for medical records was used (Cerner, Kansas City, MO), which will promote continued access during a regional disaster. The hardened interstitial floor was designed to include virtual server components for our electronic medical records.
Similar to other hospitals, ACH JHM created a distinctive disaster response policy and team. To accommodate this team of responders, ACH JHM has provided gender-appropriate housing, food, medications, and shower space. Disaster response teams will be provided with regular access to food, medication and self-care products, which are located in large walk-in freezers in the basement and first floors of the hospital. Gas power with electric backup ensures that the supply of nonperishable food products can be supplied and prepared for employees during the disaster. Immediate and necessary supplies also have been included in a disaster locker (Table) to allow ACH JHM’s emergency responders increased preparedness to execute the critical services needed during the first hours and days of a disaster.
To avoid damage and failure associated with pipe breakage, flooding, broken windows, and flying debris, all mechanical equipment and intakes, pumps, and switchgear were placed in hardened space with shutters or no windows at the hospital’s fourth level or above.
High-resolution cameras provide an extensive overview of the facilities. Cameras in parking garages capture license plates of vehicles entering and leaving ACH JHM, and dedicated computer storage allows continuous recording of active cameras. All doors of the building can be automatically locked down to prevent potential looting and forced entry/exit during disasters and recovery phases.
Evacuation efforts during Hurricane Katrina were crippled by the inability of military-grade helicopters to land on hospital helipads because of weight limitations and rotor length clearance. Thus, ACH JHM’s helipad was designed to accommodate a Black Hawk military helicopter weighing up to 36,000 lb and having a 66-ft wingspan. The helipad is connected to transport elevators that are immediately adjacent to critical patient areas of the hospital for ease of transfer and acceptance of patients during disasters, as well as the upsizing of the hospital that is anticipated during a regional disaster (Fig. 2). ACH JHM’s geographic position, one of the highest points in the county, reduces the risk of closing our emergency entry routes, thereby facilitating access by the “walking wounded” and other transport teams.
Water Supply and Treatment
ACH JHM’s well will provide water to the cooling towers to continue air conditioning services, which are viewed as critical for the well-being of patients and employees in the Florida climate, which is hot and humid. This was a critical lesson learned from the Hurricane Katrina disaster, in which the working environment was not sustainable for patients or disaster response teams because of the extreme summer temperatures. A potable reverse osmosis system capable of providing potable water was developed so that the hospital would fulfill CSSP principles in the event of disruption of local government–supplied power or services. This innovative system, available at only a select number of hospitals, allows for the proper handling of human waste, maintains a pressurized sewer system, and allows plumbing to function normally.
Recent disasters provide a reminder to healthcare leaders of the importance of disaster planning and preparedness for hospitals to function optimally during and after a catastrophic event. In the process of planning a new freestanding children’s hospital, we engaged our employees in an organization-wide stakeholder process to analyze the important components in new facility design. CSSP was a guiding principle in this process, which enabled the executive leadership of ACH JHM to analyze and deliberate on the information that is most important to hospital design and construction.
A comprehensive vulnerability assessment was used as a starting point, and we considered lessons learned historically from disasters, particularly Hurricane Katrina, and those from our own institution. Learning from experience allowed our leaders to adapt hospital design and construction for optimal disaster functionality. Before the design and construction phases, the stakeholder process incorporated pragmatic and visionary planning and allowed our executive leadership and board of trustees to create a hospital using a set of new standards for best practices that would ensure optimal functionality in the event of a disaster.
There is no substitute for the best preparation in planning for the worst, and we believe our facility and employees are prepared should a disaster occur in the region. If a disaster strikes, then ACH JHM is prepared to rely on the principles and pragmatics of CSSP and to function as an island of security in the midst of the storm.
We are indebted to the vision and leadership of the ACH JHM board of trustees and the All Children’s Foundation board. We thank employees of ACH JHM, who, as dedicated healthcare providers and administrative staff, remain committed to the mission and vision of ACH JHM. We acknowledge the engineers and architects Karlsberg and Associates and TLC Engineering, who carried out the fundamentals of CSSP in program design and building the new hospital, and Brasfield and Gorrie Builders. We also thank Valarie Collins for assistance in the preparation of this article.
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