Conrad, Erich J. MD,; Lavigne, Kimberly M. MD
From the Louisiana State University School of Medicine, New Orleans.
Reprint requests to Dr Erich Conrad, Louisiana State University School of Medicine, 1542 Tulane Ave, 2nd Floor, New Orleans, LA 70112. Email: email@example.com
The authors have no financial relationships to disclose and no conflicts of interest to report.
Accepted July 4, 2012.
Objectives: Little is known about patient populations that remain during or after the mandatory evacuation of a city and use hospital services. This study sought to characterize the population that presented to an emergency department during Hurricane Gustav in 2008.
Methods: This was a retrospective chart review of patients who presented to the Interim Louisiana State University Hospital emergency department in New Orleans during the 72-hour activation phase of Hurricane Gustav.
Results: Of the 104 patients, 51 (49%) had a psychiatric diagnosis. Among the psychiatric patients, 34 (67%) had a substance use disorder diagnosis, 16 (31%) had a mood disorder, 13 (25%) had a psychotic disorder, and 4 (8%) had an anxiety disorder. The psychiatry service was the most used consultation service.
Conclusions: To our knowledge, this is the first report to characterize the patient population presenting to an emergency department during a hurricane evacuation. Data suggest that disaster preparedness should include psychiatric consultation services. The consultation psychiatrist may anticipate patients with high levels of substance use disorders and the need for ongoing psychiatric management until the event ends.
* High rates of psychiatric disorders were present in the patients presenting to the Interim Louisiana State University Hospital emergency department during Hurricane Gustav.
* High rates of substance abuse disorders were present in the psychiatric patients presenting to the emergency department during Hurricane Gustav.
* The psychiatric consultation team was the most-used service during the hurricane’s activation phase, and this should be taken into account in hospital disaster preparedness.
In anticipating a disaster, multiple medical specialty services are present in a hospital, prepared for a wide variety of patient presentations. The purpose of this study was to review and characterize the patient presentations to the Interim Louisiana State University Hospital (ILH) in New Orleans during Hurricane Gustav in 2008. We sought to assess the need for psychiatry consultation service integration in disaster preparedness teams.
Disasters threaten personal safety, overwhelm defense mechanisms, and disrupt community and family structures. They also may cause mass casualties, destruction of property, and collapse of social networks and daily routines.1 Bishop and Thornby administered a survey to mental health care providers to medical evacuees during Hurricane Katrina regarding cases encountered, psychopharmacological interventions, and mental health support for evacuated medical personnel. They concluded that in major disasters, psychiatric consultants are likely to play a critical role in providing emergency mental health services for both medical evacuees and evacuated medical professionals.2
Given the obvious potential for psychological complications in anticipation of a life-altering event, research exploring the role that psychiatric consultation plays in multidisciplinary disaster preparedness teams is needed. A familiar research focus has been postdisaster response and disease prevalence.3 Because disasters such as tsunamis, earthquakes, and terrorist attacks are unanticipated, they do not allow adequate time for preparedness research, and the aftermath must be studied.4 Events for which there is adequate warning, such as a hurricane or typhoon, allow research of the patient population and systems needed to determine optimal preparedness. Of particular interest is the potential patient population that remains in the city or town during or after its evacuation and uses hospital services.
ILH is a 250-bed, academic, level I trauma center that was previously the west campus of the Medical Center of Louisiana at New Orleans before Hurricane Katrina struck. The Charity Hospital east campus remains closed and ILH continues the mission of training students and residents and caring for the populace of New Orleans. In 2008, the population of Orleans Parish was 311,853, and a mandatory evacuation of the entire city of New Orleans took place in anticipation of Hurricane Gustav’s landfall.5 ILH remained open to provide care to any citizens, first responders, and city personnel who were required to shelter in place.
The inpatient psychiatry units were evacuated to another city, and the general hospital was reduced to as few patients as possible. The psychiatric emergency services were moved from vulnerable trailers located on the grounds of ILH into a section within the main hospital. The consultation psychiatry service remained to serve the hospital with one faculty and one resident psychiatrist who were both required to remain in the hospital for the duration of the event.
We conducted a retrospective chart review of the patients who presented to the ILH emergency department during the activation phase of Hurricane Gustav. Activation phase refers to the period of time immediately preceding a hurricane and the recovery time after it strikes. For Hurricane Gustav, which made landfall September 1, 2008, the ILH required that physician disaster personnel report to the hospital August 31, 2008 and stay onsite until September 2, 2008.
In accordance with the local institutional review board, charts were reviewed for all of the patients who presented to ILH from August 30, 2008 to September 2, 2008 to discern the primary reason for the emergency department care. In addition to demographic information, the charts were reviewed to note the interventions-required disposition of the patient and the existence of any factors that potentially contributed to this presentation, including psychiatric diagnoses. Data also were collected on the different specialties consulted to care for patients presenting to the emergency department.
We hypothesized that many of the patients encountered at the emergency department during the activation period for Hurricane Gustav would exhibit a variety of psychiatric disorders such as mood, psychotic, and substance use disorders. In addition, the number of patients requiring psychiatric consultation would be significantly higher when compared with other medical specialties.
The Table summarizes the characteristics of patients presenting to the ILH emergency department by 24-hour period. Of the 104 patients who presented from August 30, 2008 to September 2, 2008, 51 (49%) patients had a psychiatric diagnosis. Among the 51 psychiatric patients, 34 (67%) had a substance use disorder diagnosis, 16 (31%) had a mood disorder, 13 (25%) had a psychotic disorder, and 4 (8%) had an anxiety disorder. Psychiatry was the most highly used consultation service during Hurricane Gustav.
Table Hurricane Gust...Image Tools
Hurricane Gustav made landfall west of New Orleans, so major damage to the city was avoided. There was a dramatic drop off in patients presenting from August 30, 2008 through September 2, 2008 as a result of the mandatory evacuation of the citizens of New Orleans that began on August 31, 2008.
During the activation period, psychiatry consultation was sought in 9% to 38% of total presentations to the emergency department per day, compared with all other services consulted for 0% to 10% of total presentations per day. This is in contrast to a typical day at the ILH emergency department, with an average of 189 patient presentations, 12 (6%) of which require psychiatric consultations. The patients who presented to the emergency department after August 31, 2008, could not be discharged because of the mandatory evacuation and lack of any services for inpatient or outpatient psychiatric care; therefore, ongoing consultant care of all patients continued during the activation period. By the end of September 2, 2008, the psychiatry service was actively responsible for 11 patients boarding in the emergency department.
Most other hospital services were essential to ensure the possibility of responding to complex surgical and medical care; however, the primary service used during the activation period was psychiatry. Although the experience at ILH may not be generalizable to other hospitals or cities, this information should be taken into account for future plans in areas that are vulnerable to hurricanes or typhoons.
Our experience supports the report from Norwood et al, who posited that psychiatric involvement in predisaster planning is critical to successful intervention in the aftermath of a tragedy.6 In addition, they stated that because every hospital must establish and exercise a disaster response plan to meet the requirements of The Joint Commission, psychiatrists should ensure that plans include psychiatric considerations. The requirements do not specifically address psychiatric care during an event, such as the one described here; instead, most guidelines focus on coping with the aftermath of a disaster. The Executive Summary of Psychiatry Disaster Guidelines and Models for Hospitals suggests clear plans for preparing, coordinating with others, and training that need to be applied to each individual hospital system.7 The results above may aid others in determining what they may need and should expect if placed in a similar situation. This knowledge also may expand the potential role of consultation-liaison psychiatrists, in particular, in local disaster preparedness planning.8
To our knowledge, this is the first report to characterize the patient population presenting to an emergency department during a hurricane evacuation. The data suggest that disaster preparedness under such circumstances should include psychiatric consultation services. The consultation psychiatrist may anticipate patients with high levels of comorbid substance use disorders and the need for ongoing management until the event ends and routine services resume.
1. Lubit R, Rovine D, DeFrancisci L, et al.. Impact of trauma on children. J Psychiatr Pract 2003; 9: 128–138.
2. Bishop L, Thornby J. Psychiatric consultation with medical evacuees of Hurricane Katrina. Wilderness Environ Med 2009; 20: 1–5.
3. Raphael B, Ma H. Mass catastrophe and disaster psychiatry. Mol Psychiatry 2011; 16: 247–251.
4. Claassen C, Kashner TM, Kashner TK, et al.. Psychiatric emergency “surge capacity” following acts of terrorism and mass violence with high media impact: what is required? Gen Hosp Psychiatry 2011; 33: 287–293.
6. Norwood A, Ursano R, Fullerton C. Disaster psychiatry: principles and practice. Psychiatr Q 2000; 71: 208–226
8. Locke SE. Psychosomatic medicine and biodefense preparedness—a new role for the American Psychosomatic Society. Psychosom Med 2006; 68: 698–705.