How hospital emergency preparedness is evolving

The biggest lesson that COVID-19 has taught hospitals is how thin they can be stretched—and that includes morale, says Dr. Yves Duroseau, chief of emergency medicine and co-chair of disaster planning services at Lenox Hill Hospital in New York.

Over the past nearly three years, “We’ve seen widespread staff burnout trying to go above and beyond, every day. It’s not sustainable — it’s too overwhelming,” he says. “So now we are considering what to do, because COVID is still a threat, and now we are considering problems like monkeypox and polio. Everyone is asking: What’s next?”

However, the new wave of the pandemic is far from the only potentially debilitating event facing hospitals. Most health centers are continually revamping their multi-level emergency preparedness strategies, Duroseau says. Like a seemingly never-ending action movie, threats shoot out from all sides. Some vary by location: Hospitals must be prepared for hurricanes along the Gulf and Atlantic coasts, for example, and earthquakes and wildfires on the West Coast.

Taking steps to plan for the next emergency—even if no one knows exactly what it will look like—can help build resilience. Here’s a look at the five biggest challenges hospitals are currently facing, followed by the preparedness plans they’re implementing.

1. The next epidemic

While COVID-19 may have caught many hospital systems off guard, it has shown just how far an infectious agent can spread – and how quickly. Hospital systems must now ensure they are ready next time.

“Nobody believes we’re past current and future threats when it comes to epidemics and pandemics,” says Eric Alberts, senior director of emergency preparedness at Orlando Health in Florida. “Every hospital is still on high alert when it comes to trying to predict what’s next.”

2. Violence in the hospital

The US Bureau of Labor Statistics reports that the rate of injuries from violent assaults on medical professionals increased by 63% from 2011 to 2018, and the Association of American Medical Colleges (AAMC) notes that it has only gotten worse since then. In a recent survey conducted by National Nurses United, nearly half of the nurses who responded said they had experienced violence in the workplace, mostly initiated by patients. The situation is so serious that some hospitals have created de-escalation teams to calm aggressive patients.

The emergency department is particularly prone to violent outbursts. In one AAMC study, nearly half of emergency physicians reported being assaulted and 70% of emergency room nurses reported being punched or kicked while on the job.

3. Climate changes

The US Environmental Protection Agency notes that rising global temperatures are associated with significant changes in weather patterns, which can lead to extreme weather events such as heat waves and droughts, more intense hurricanes, frequent tornadoes, floods and wildfires.

Of course, this means more people will need medical attention due to the weather. But it also leads hospitals to new disruptions and possible closures. When Hurricane Ian hit Florida this fall, 16 hospitals in the state had to evacuate patients. In December 2021, a Colorado hospital had to evacuate its entire neonatal intensive care unit due to wildfires — at a time when it was understaffed due to the winter holidays. Such incidents will continue to become more common, Alberts believes, putting enormous pressure on patients and their caregivers.

4. Cyber ​​threats

Cybersecurity threats to healthcare systems have been on the rise in recent years. Ransomware—when an attacker paralyzes a hospital’s computer system and demands a ransom to free it—is particularly on the rise. According to the AAMC, this type of cyberattack has increased during the pandemic, with one estimate stating that about 1 in 3 healthcare organizations worldwide were affected by ransomware in 2020.

These incidents not only put organizations at risk – they can also affect patient care. For example, in October 2020, the University of Vermont Medical Center suffered a ransomware attack that prevented employees from accessing electronic health records, payroll programs, and other digital tools. Appointments for patients could not be scheduled, and most operations had to be postponed. Although the health system declined to pay the ransom, it estimated that the attack cost $50 million in lost revenue.

5. Limited internal resources

Hospitals struggling to be well prepared for emergencies often struggle with issues like lack of funding, says Dr. Russ Kino, an emergency medicine specialist and medical director of the Weingart Foundation’s Emergency Department at Providence Saint John Medical Center in California.

“Most hospitals are already operating on thin margins, and those are shrinking as insurers cut coverage,” he says. “Financially and organizationally, we are in a tight and difficult position.” In addition, he points out, the average length of service of a hospital director is about 18 months. “So you usually have leadership changes, and that can throw off any emergency preparedness plans.”

The overall staff is another matter. According to a report by NSI Nursing Solutions, which surveyed more than 3,000 US hospitals in January 2022, the average hospital turnover rate is 25% per year, and is even higher for nurses at 27%. At the same time, the demand is growing – the American Nurses Association estimates that there will be more nursing jobs available in 2022 than any other occupation in the country. All of this means that as hospitals have to do more when it comes to emergency preparedness, they often do it with less staff.

Read more: Caring for caregivers after the pandemic

How hospitals are progressing

While the main threats facing hospitals may sound unrelated — cyber threats and hurricanes don’t overlap, for example — they’re related in part because of how they need to be dealt with, Duroseau says. Many hospitals use several main strategies: planning for the worst possible scenario; conducting training exercises for these capabilities; strengthening cooperation inside and outside the hospital; and renovation with climate change in mind.

For example, Providence Saint John Medical Center regularly conducts unplanned drills for active shooter situations, which helps ensure that staff can close and lock down parts of the hospital within minutes. Lenox Hill Hospital does the same, and staff there are also trained in potential mass casualty events that could bring dozens of seriously injured people to the emergency room at once.

“These types of exercises allow us to see where the gaps are in process and personnel,” Duroseau says. “This is particularly important in times of high staff turnover, which we experienced during COVID.”

Similarly, Lenox Hill conducts drills for cyberattacks that would disable an entire computer system or compromise patient care. Duroseau notes that many pieces of hospital equipment, such as the infusion machines that deliver drugs, run on a web platform, meaning they could theoretically be hacked. The idea that a cyber attacker could deliver a lethal dose of painkillers from thousands of miles away is terrifying, he says, which is why the hospital is training staff to switch to a manual, offline system during such a scenario.

“It’s hard to play offense in a cyber situation,” he says. “At least we can train people to deal with outages in a way that protects patients. In general, we all know the areas of vulnerability we have with each type of threat, and there’s only so much we can do to counter it. But we can try.”

Another key aspect to threat management is cooperation with local and national agencies such as fire departments, police, state health departments and the Federal Emergency Management Agency, Alberts says.

“If you take threats seriously, there’s a lot you can do in advance if you plan ahead,” he adds. “Internal coordination and coordination with these external stakeholders truly helps us better prepare for and respond to crises of all types and sizes. Having the right people in the right place at the right time is a big factor in any hospital system’s response to a threat.”

That kind of collaborative perspective can help ease tensions in other ways, too, by creating stronger policies between hospitals and their suppliers, he adds. For example, during the first year of the COVID-19 pandemic, healthcare systems struggled to provide enough personal protective equipment. That situation is unlikely to happen again since hospitals have developed much more robust procurement and storage policies, Alberts says.

The same philosophy extends to the prevention of cyberattacks. For example, Lenox Hill now works closely with its software vendors to ensure that multiple levels of electronic security protection are in place. “We never asked our technology vendors what they built in for security—we just wanted to know about the overall functionality,” Duroseau says. “Now, that’s the first thing we think about [evaluating] new technical contract.”

Planning weather events can be simpler. Hospital staff can analyze the type of weather problems that have caused problems in the past—and then magnify them to an extreme level. For example, this may mean preparing for record snowfall in North Dakota, fortifying walls for multiple tornadoes in Kansas, building new structures on high ground in Florida, or securing a fireproof perimeter in California. Some hospitals may even relocate — managers of several hospitals damaged by Hurricane Ian said they are considering moving inland to protect against future storms.

“This is an ongoing problem and we’re constantly trying to better understand it, because the effects of climate change will continue to be a big threat,” says Alberts. “Hurricane Ian showed everyone how much precipitation can fall in such a short amount of time, giving us all a great opportunity to use this data for future efforts.”

Looking ahead

One of the most difficult challenges in preparing for major threats is not unique to hospitals: it’s simply not knowing what lies ahead. As Kino points out, there is no way to plan for all possible contingencies. But there is always hope that the threat, once it develops, can be dealt with resiliently and effectively.

“Despite everything that’s happened in the last two years, we know we’re doing amazing and stimulating work,” says Kino. “Even on hard days, we’re still a team and deep down we love our job – that’s why we’re here. It’s pretty amazing to look back and see what we’ve accomplished through pandemics, widespread burning, mass casualty events, and climate change. We found a way, and I think that’s what drives every hospital right now: we know we’ll always find a way.”

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