Lessons from Joplin

12-08-2013

Lessons from Joplin

The massive tornado that hit Joplin in May 2011 tested the emergency operations plans of the area’s hospitals to their limits. Leslie Porth, author of a report on the lessons learned from Joplin, gave HRMR an overview of her findings.

When an immense EF5 tornado struck St John’s Regional Medical Center (now called Mercy Joplin Hospital) in Joplin, Missouri, on May 22, 2011, the results were catastrophic. Windows shattered, spraying glass over staff and patients. Some people were sucked outside into the parking lot; others were left struggling for their lives after their ventilators stopped working and the emergency power generator failed to kick in.


Patients’ IV lines were torn from their arms by the force of the wind. In the stunned silence that followed in the wake of the tornado, staff struggled to evacuate patients, some of whom were without shoes yet had to walk across broken glass as they were hurriedly moved to neighbouring hospitals. When the time finally came to take stock of the devastation, it was discovered that of the 183 patients at St John’s that Sunday night, five had died as a result of the tornado.


The tornado was the most severe of a string of natural disasters that struck Missouri in 2011. January brought blizzards and floods to the southeast and northwest; in April and May two serious tornadoes struck, the first in St Louis and the second in Sedalia.


Fortunately the preparedness efforts of preceding years paid dividends: hospitals in the affected areas were able to activate emergency operations plans (EOPs) and incident command systems (ICS) effectively to respond to these non-catastrophic disasters.


However, plans and exercises did not fully address the devastation and overwhelming patient surge that resulted when the tornado of May 22 wiped out much of the Joplin community, including nearly half of its healthcare resources.


“One hospital was destroyed, and several other hospitals in the immediate and surrounding area sustained structural damage and loss of major utilities include power, water and communication systems,” says Leslie Porth, vice president of health planning for Missouri Hospital Association (MHA) and author of a report titled Preparedness and Partnerships: Lessons Learned From the Missouri Disasters of 2011.


“In addition to damage, many of the surrounding hospitals were affected by the disaster-related medical surge which was catastrophic both in complexity and volume,” she adds.


DEADLIER THAN ANTICIPATED
The main problem faced by hospital staff was the fact that planning efforts had not adequately anticipated the sheer magnitude of destruction to the medical corridor of Joplin and the catastrophic number of injuries and fatalities. Around 158 people were killed by the tornado and 1,100 were injured, making it the deadliest tornado to strike the US since the Texas-Oklahoma tornado of 1947. The cost of damage caused by the Joplin tornado ran to $2.8 billion.


Despite the surprising force of the tornado, existing emergency plans did serve to guide the hospitals’ responses to good effect. One of the most important elements was the Missouri Hospital mutual aid agreement (MAA), signed by approximately 92 percent of the state’s hospitals.


“The MAA provided the legal and financial framework for hospitals in Missouri to lend and receive resources during the disaster response,” says Porth. “The MAA is one of the architectural components for regional collaborative planning among healthcare professionals to establish formalized relationships and expectations. The MAA was activated immediately following the tornado, resulting in resources arriving, including staff, immediately after it struck.”


The success of the MAA highlights the importance of planning across a broad geographical area and a wide range of facilities.


“The disaster demonstrated the value of regional planning, including different industries and jurisdictions,” says Porth. “Collaborative planning followed by extensive exercises to break the plans must be a priority.”


While an EOP may be unlikely ever to provide exact response instructions, it does equip staff with critical thinking skills needed to anticipate and respond to a disaster.


“Emergency preparedness planning must not be an exclusive process; all employees and medical staff must know and understand the EOP,” she states. Furthermore, regional and state coordination are essential for this planning process. “Know your partners. Plan and exercise together,” she advises.


COMMUNICATION
Porth believes the number one lesson learned as a result of the tornado is the importance of effective communication. Strategic communication is necessary for coordination with employees, the public and the media, and social media must be part of this strategy.


“In this era of social media and immediate global dissemination of information, the message conveyed during a disaster is immediately two-directional. The message can no longer be controlled by the organizations and entities responding to the disaster. This requires hospitals to be prepared to respond immediately and coordinate information with others through a joint information center,” states the report.


The communication trailers purchased through the federally-funded Hospital Preparedness Program grant and deployed for the Joplin response through MHA’s mutual aid agreement provided reliable access to Internet, radio and phone for Freeman Health System, Freeman Neosho and Landmark Hospital of Joplin.


However, Porth emphasises, staff should also be trained to use traditional forms of communication. Computers and Internet access may be lost, so crucial information needs to be printed and stored in multiple places in the building. Grab-bags with paper, pencils, printed forms, flashlights and batteries should be stored throughout the hospital. It is also advisable to enlist the help of amateur radio operators, and create a regional amateur radio ‘strike’ team who would make themselves available in an emergency. All partners need to agree in advance on common radio frequencies. Says Porth: “You cannot have too many radios.” Solar charging stations for cellphones are also an excellent idea.


Social media such as Twitter need to be incorporated as a strategy into your organization’s EOP. Porth advises assigning a public information officer (PIO) immediately when disaster strikes. “If the event is community-wide, ensure the PIO is coordinating the messages and media with other PIOs through a joint information center,” she states. “You should also have a plan that outlines what information can and cannot be shared and why—and you need to ensure consistency among all PIOs and liaisons.”


RESOURCES AND ASSETS
Resources and supplies are vital to any emergency response but just-in-time delivery systems are not reliable in disasters; blizzards, floods and catastrophic damage can prevent re-supply or quickly deplete resources. Missouri hospitals planned effectively in advance of the January blizzards and were well equipped to cope with the supply interruptions caused by the Joplin tornado.


“The Freeman Health System incident commander immediately assigned responsibility to one individual to evaluate supply levels and monitor use,” states Porth. “This action resulted in prompt resupply and acquisition of critical supplies. The unified command logistics branch for the Mercy system coordinated and delivered immediate and exact supplies for Mercy Joplin Hospital from its system warehouse in Springfield.”


The use of MAAs, including the one coordinated by MHA, enabled the immediate movement into the Joplin area of resources from hospitals and other entities outside the affected area. Crucial to the successful sourcing and distribution of these resources and assets was the deployment of a dedicated person to evaluate supply levels, monitoring use and anticipating needs beyond supplies. This role—allocated at the onset of a disaster—is “a critical responsibility”, says Porth.


SAFETY AND SECURITY
“In every Missouri disaster in 2011, the safety of staff, patients and visitors and securing critical resources were urgent needs requiring immediate action,” says Porth, who stresses the importance of having safety measures in place to cope with the surge of media and public attention that often accompanies a major event. In a county-wide disaster local law enforcement cannot be relied upon for help, so it is wise to develop a security response team in your EOP and to ensure that security staff can be quickly and easily recognised.
If serious infrastructural damage occurs, pharmacies and nuclear medicine


STAFF AND VOLUNTEERS
Porth believes that perhaps the single most important planning consideration is how to manage and support hospital staff during a response and throughout the recovery. “Take care of your staff,” she advises. Catastrophic events at a hospital create a unique set of pressures, because the staff are at once both victims and responders. You can expect their ability to respond effectively to be diminished, and need to plan accordingly.


In addition to your regular staff, you may be presented with volunteers arriving and offering to help.
“Have a plan to divert or accept, credential and use volunteers who arrive on scene without basic lodging and food provision,” advises Porth. You need to bear in mind that you might find yourself in a situation without a coordinating agency to verify individuals’ names, credentials and competencies.


UTILITIES
Utility failures topped a list of priority risks identified by hospitals in a 2012 MHA Capacity Assessment. “The requirement of a hospital to plan for a safe environment and manage a sudden or sustained influx of patients is not dependent on utilities,” advises Porth. “Consider redundant systems and agreements for auxiliary sources of water and power.”


MEDICAL SURGE
Managing the surge of patients that accompanies a disaster can require innovative solutions regarding staff, supplies and space. “The need to understand the balance between managing a surge of patients and recognizing the need for regional, state or federal resources or support is critical to ensuring patient safety,” states Porth.


“EOPs must establish detailed procedures for providing patient care in conventional, contingency or crisis settings, and transition plans must be clearly delineated. Planning for medical surge requires innovative solutions to staff, supplies and space limitations.”


EVALUATION
Ultimately, only thorough planning can equip a hospital or an area to deal with an event such as the Joplin tornado. Porth sums this up with the following advice: “Plan for failure! Test to failure! Identify break points. Revise and correct the plan. Retest to failure!” 

tornado, Joplin, Missouri, crisis, evaluation, Leslie Porth, Crisis management