Leadership

Emergency Preparedness among Top 10 Patient Safety Concerns

With 2017 in the record books as the costliest year for U.S. natural disasters, ECRI Institute identified all-hazards emergency preparedness as a top 10 patient safety concern for 2018 (ECRI Institute "Top 10"). Patients' needs for healthcare do not stop when a disaster strikes. In fact, in a disaster's aftermath, demand for healthcare services often increases. During and after a disaster, hospitals must be prepared not only to treat the disaster's victims, but also to manage the disaster's effect on its own staff and infrastructure.

"A disaster can happen anywhere at any time," says Mary Parsons-Snyder, MBA, BSN, RN, ECRI Institute patient safety analyst and consultant. "It's not a matter of whether, but when, a disaster lies in your future. You have to be prepared," she says. Hurricane Maria, for instance, left few functioning hospitals in its wake after it ripped through Puerto Rico in September 2017 (Holpuch).

Besides responding to 2017's costly disasters from floods, hurricanes, wildfires, and more, hospitals throughout the United States pulled out their emergency plans to cope with manmade disasters, such as train crashes, mass shootings, and cyberattacks, all of which placed demands on healthcare services. After last year's deadly mass shooting in Las Vegas, for example, one hospital near the incident received 150 patients within 40 minutes of the shooting. The hospital typically treats 300 patients each day in its emergency department (Tanner).

Unfortunately, there is no sign that external disasters, either natural or manmade, will decrease in number or intensity. Climate change, globalization, terrorism, and increased reliance on the internet ensure that natural disasters, pandemic and mass casualty events, and cyber threats are not going away.

Without preparation, natural and manmade disasters, as well as internal facility disasters, can have severe consequences for healthcare facilities, staff, and patients.

Unsafe conditions in the face of disaster can also damage a facility's reputation. After last year's Hurricane Harvey, a photo showing nursing home residents sitting in water up to their knees quickly went viral. Then following Hurricane Irma, a Florida nursing home made headlines when 14 residents died from heat-related causes after the storm knocked out power.

Disasters Can Strike without Warning

Preparation is especially important because disasters can hit without warning. In August 2015, typhoon Soudelor, the strongest typhoon in the northern hemisphere in nearly a century, veered off its predicted path and headed directly for Saipan, the largest of the Northern Mariana Islands, a U.S. commonwealth. The storm caused widespread damage, knocking out power on the island for weeks. The commonwealth's sole hospital, operated by Commonwealth Healthcare Center (CHC), had activated its incident command center before Soudelor hit and was ready. The hospital became a refuge for the island's residents in the weeks after the typhoon, when water and power were unavailable, and provided much-needed care to its community.

"If we were complacent, we would not have survived," says Warren F. Villagomez, CHC's program director of public health/hospital emergency preparedness. "We never let our guard down," agrees Esther Muna, CHC's chief executive officer. "Preparedness is a must for every hospital," she adds. "We know how difficult it can get." Refer to When Disaster Strikes: One Hospital's Experience for more information about CHC's recovery from Typhoon Soudelor.

Tallying the Damage

Sixteen weather and climate disaster events with losses exceeding $1 billion each hit the United States in 2017, according to the National Oceanic and Atmospheric Administration (NOAA). As illustrated in Figure 1. Billion-Dollar Disaster Events by Year, the number of severe storms with losses exceeding $1 billion, adjusted for inflation, is climbing. From 1980 through 2017, there were an annual average of 5.8 costly events, whereas in the most recent five years (2013 through 2017), the annual average climbed to 11.6 events. (NCEI)

Even more remarkable is the cumulative cost of more than $300 billion for severe events in 2017, which surpasses the record of $215 billion set in 2005 due to Hurricane Katrina and other storms. (NCEI)

CMS Requirements

As CHC and others have experienced, a healthcare facility serves as an essential resource to its patients and community during and after a disaster. Preparedness "ensures that the facility and workers are able to do their jobs" to deliver safe patient care, says Parsons-Snyder. 

"I challenge hospitals to work with their local authorities to prepare," says Parsons-Snyder. "Touch base with each other. Share your emergency preparedness lessons and policies. Network and get to know your partners."

Hospital leaders must also be ready to devote resources to emergency preparedness or, otherwise, make tough decisions about the facility's future. In earthquake-prone California, a few facilities have closed because they cannot afford to upgrade to the state's updated hospital seismic safety law (Karlamangla).

Starting in November 2017, the Centers for Medicare and Medicaid Services (CMS) is requiring healthcare providers of all types that participate in the Medicare and Medicaid programs to follow best practices that incorporate four principles for emergency preparedness (CMS):

1. Develop an emergency plan based on an analysis of the emergencies and disasters most likely to have an impact on a healthcare facility and its surrounding community.
2. Develop and implement policies and procedures to enact the emergency plan.
3. Develop a communication plan to ensure patient care is well coordinated within the facility, across healthcare providers, and with state and local public health departments and emergency systems.
4. Conduct training and testing of the emergency plan with staff training and drills that test the plan.

"Facilities that do not have plans established prior to an emergency or a disaster may face difficulties providing continuity of care for their patients. In addition, without proper training, healthcare workers may find it difficult to implement emergency preparedness plans during an emergency or a disaster," CMS said in its final rule. (CMS)

The rule outlines emergency preparedness requirements for 17 types of providers, including hospitals, nursing homes, home health agencies, and hospice programs (refer to Are You Prepared? for a list of the 17 provider types). Although emergency preparedness is not new to hospitals, it is new to some of those on the CMS list, such as organ procurement organizations. Among groups excluded from the requirements are fire and rescue units, ambulances, and single- and multispecialty medical groups.

The American Hospital Association calls the rule a "commonsense" approach to help healthcare facilities protect patients and communities during disasters and applauds CMS for aligning its requirements with other standards-setting organizations, such as the Joint Commission and the National Fire Protection Association (AHA). The final rule's requirements vary somewhat for the different provider types; this article focuses on the obligations of hospitals.

Learning from Experience

Since the 2001 attacks on the World Trade Center, hospital preparedness has shifted to more comprehensive emergency management planning as outlined in the CMS rule. Healthcare facilities are continually applying the lessons learned from drills and actual events to understand what they are doing right and what can be done better. As destructive as Hurricane Harvey was to Texas facilities in 2017, it could have been worse. After Tropical Storm Allison devastated southeast Texas in 2001, the region's medical services invested an estimated $1 billion to harden medical centers against flooding. For instance, they installed submarine doors to block rising waters and relocated backup generators and transformers to higher floors, and they routinely conduct drills to prepare staff. Without that work, Harvey would have been far worse for the region's medical services. (ASPR "Evacuating"; Phillips et al.)

Organizations can also learn from their own experience, and their event reporting systems can serve as a resource to detect their specific emergency preparedness gaps. ECRI Institute PSO examined disaster-related events submitted to its database to better understand how disasters affect healthcare organizations and their ability
to deliver patient care.

The results were surprising. Few reports addressed issues arising from any type of disaster, leading ECRI Institute PSO to conclude that organizations are missing an opportunity to improve their emergency preparedness response by failing to collect events about the effects of disasters on patient care. Regulatory requirements to report disaster-related events affecting the facility to external agencies may limit reporting of these events through the organization's traditional reporting systems. This issue of the PSO Navigator summarizes the findings from the analysis and recommendations for improving emergency preparedness.

What We Are Seeing

Disaster Events Submitted to ECRI Institute PSO

In the near decade that healthcare organizations have been reporting events to ECRI Institute PSO, very few describe the consequences of disasters on care delivery, even though during that time, facilities have experienced hurricanes, floods, tornadoes, cyber threats, disease outbreaks, and more.

For its analysis, ECRI Institute PSO queried its database for events associated with disasters occurring from January 2015 through December 2017. The keyword search included specific disaster-related terms (e.g., outage, disaster, hurricane, fire, flood, generator, shooter, shooting). The search yielded more than 3,700 events, many of which were irrelevant (e.g., the word "generator" in the event description referred to a device generator, such as a pacemaker).

Based on a random review of the events, an ECRI Institute PSO analyst determined that most disaster-related events are classified by reporters under the event category for environment. Narrowing the results to only those events grouped as environmental yielded 100 events, of which 29 qualified as a disaster-related issue. For many of the 29 events, there is no indication whether the disruption was from an internal or external disaster. One event, for example, simply states, "a power outage occurred during an outpatient procedure."

Only 10 of the 29 events indicated a harm score. ECRI Institute PSO's enhanced event reporting system incorporates the National Coordinating Council for Medication Error Reporting and Prevention's (NCC MERP) Index for Categorizing Medication Errors to indicate harm levels. The index—with its nine categories for harm, labeled A through I—is used to indicate an event's effect on the patient. The harm scores are provided by the reporting organization. Events with a harm score of E through I are associated with patient harm.

Of the 10 disaster events with a harm score, three were given harm scores that indicated patient harm (one event had a harm score of E and two had an F harm score). All three events were associated with procedures that had to be stopped because of a power outage.

As shown in Figure 2. Triggers of Environmental Events that Could Spell Disaster, the majority of the disaster-related events were caused by power outages (83%), followed by fires (7%) and fumes (7%).

Medical Equipment Vulnerable

Several power outage events described effects on medical equipment operation as in the two following events:*

Due to the power outage, the call bell system malfunctioned. It was not possible to alert the unit and it was not possible to alert the unit of an actual obstetrics emergency.

The power in the NICU [neonatal intensive care unit] flickered on and off. With each power outage, patient monitors and some patient equipment were affected. We had no access to patient vital signs while the monitors were down. A phototherapy unit to treat a patient with hyperbilirubinemia shut off, and an incubator, which had a patient in it at the time, had to be rebooted.

An overnight power outage nearly prevented a special-procedure unit from proceeding with its caseload for the next day if medical equipment could not be reprocessed in time.

There was a power outage to the building at 11:30 pm. The command center opened at 1 am. At 4:30 am, lower voltage power was restored. By 6 am, power was restored to the central processing department's sterilization equipment. Most first- and second-case instruments were processed with a backup plan for the remaining scheduled cases.

For more information about the effect of power outages on operations, refer to the PSO Compass Points listed in ECRI Institute Resources.

____________
* The event details are deidentified for these and all other events summarized in this report.

Procedure Cancellations

Several reports described procedures that had to be cancelled. In one case, a power outage forced operating room staff to cancel a transplant procedure that had begun.

The patient is in the OR [operating room] to receive a liver transplant. Due to a power outage affecting a great part of the city, we are unable to proceed with surgery. We were unable to contact the transplant coordinator to find out what to do with the liver since we were unable to use it.

Another outage forced a facility to stop patients' dialysis treatments mid-session:

Patients' dialysis treatments were terminated due to a power failure and a generator not functioning. All patients were encouraged to finish their dialysis sessions and offered follow-up appointments. Patients were educated on monitoring their fluid/salt/potassium intake and encouraged to go to the ED [emergency department] should any complications arise.

Damaged Supplies

One event described a weekend power outage that went unnoticed and spoiled refrigerated supplies in a doctor's office because a backup power source was unavailable for the refrigerator.

A power outage in the MOB [medical office building] started on a Sunday and lasted for two days. The refrigerator containing patient medication and supplies was not plugged into the backup generator outlet. The temperature in the refrigerator reached 75 degrees F. The medications should be stored at temperatures between 36 and 46 degrees. Medications costing thousands of dollars were disposed.

The damage to equipment and supplies can be far worse. After Tropical Storm Allison in 2001, Houston-area hospitals suffered severe flood damage. Any exposure to a combination of water, high humidity, and elevated temperatures left patient care equipment ripe for infestation with mold or other biocontaminants. At the hospitals comprising Texas Medical Center, all patient care devices exposed to water or high humidity were discarded or replaced (ECRI Institute "Healthcare").

Flooding from Hurricane Sandy in October 2012 was also devastating to NYU Langone Medical Center, which was forced to evacuate more than 300 patients, many down stairwells, after losing power, including its backup generators. The hospital used $1.45 billion in federal aid to flood-proof the facility and move critical utilities and communication networks from the basement (Barbanel).

Lessons Learned

An Ounce of Prevention

Emergency preparedness is an ongoing process. Benjamin Franklin's adage about fire safety ("An ounce of prevention is worth a pound of cure") can apply to all disasters, natural or manmade, internal or external. Precautionary measures taken before a crisis occurs can protect people and structures from devastation during and after a disaster.

Although limited in number, events related to disaster readiness reported to ECRI Institute PSO highlight the many ways that disasters can affect operations and patient care. Importantly, they also underscore the need for organizations to continually evaluate the effectiveness of their emergency operations plans. Listed below are ECRI Institute PSO's recommendations to ensure readiness for disasters of all types. These recommendations, many of which are embodied in the CMS regulations for emergency preparedness, are intended as a starting point; comprehensive resources are available, including those listed in ECRI Institute Resources and Online Resources.

Event Reporting

ECRI Institute PSO's analysis of events involving emergency preparedness underscores the dearth of information about disasters reported for event analysis and investigation.

"Organizations may not view an event from a disaster as one they created," explains Parsons-Snyder. "They don't think of these as a patient safety event that could have been prevented."

Additionally, some facilities may have other avenues for reporting the events. In Pennsylvania, for example, hospitals are required to report infrastructure failures to the state Department of Health, says Parsons-Snyder. An infrastructure failure is defined as "an undesirable or unintended event, occurrence or situation involving the infrastructure of a medical service or the discontinuation or significant disruption of a service which could seriously compromise patient safety." (MCARE)

Previously serving as an emergency preparedness coordinator at a Pennsylvania hospital, Parsons-Snyder says she typically heard about service disruptions in the daily morning huddle. "That's where I would hear if there's an issue, such as the telemetry monitors went down." If the event did not affect patient care, it was unlikely to be reported in the event reporting system.

Nevertheless, an event such as a power outage to certain telemetry monitors could indicate bigger problems. By reporting the event, an opportunity is opened to investigate what happened and take steps to prevent similar incidents that could compromise patient safety. For example, an event reported to ECRI Institute PSO resulting in a power loss to some telemetry monitors contained clues about the cause, which could have implications for the facility's preparedness practices.

All telemetry units lost their signals. The signals were not restored for 2½ hours. During the time, no telemetry signals were available for any of the patients on portable monitors, nor could any new monitors be issued to monitor new admissions. We were told the outage was caused by generator testing.

Routine testing of emergency power systems can uncover and address problems that could otherwise be devastating during an actual power outage. But testing must be conducted in a carefully thought-out manner that minimizes disruption to hospital operations. The event accentuates, first, the need to warn staff when generator testing occurs and, second, the importance of advising staff to report emergency power failures during testing. If the information about the telemetry monitor had not been reported as a patient safety event, the hospital might have missed an opportunity to address emergency power gaps that could have more serious consequences for patient care during an actual disaster.

Hazard Vulnerability Assessment

Organizations should routinely conduct a hazard vulnerability assessment (HVA) to identify high-risk hazards that are most likely to confront the facility. An "all-hazards" approach to emergency preparedness shifts the emphasis from planning for a particular type of emergency to delineating common features and strategies to use when responding to all types of emergencies and disasters identified in the assessment.

Each organization has its own risks. A hazard can be internal to the facility, such as a fire or the loss of electricity, or external, either natural or manmade. External incidents may affect the structural and nonstructural integrity of the hospital itself, damage or destroy the entire community, or have no physical effect at all while resulting in a surge of patients, such as in the event of a mass shooting in the community. Some external events evolve slowly, such as infectious-disease epidemics or hurricanes; these disasters give hospitals (and the overall community) time to activate their emergency plans in an orderly fashion, adjust resources, and request and obtain outside assistance. However, others, such as a bombing, provide little to no notice and evolve rapidly.

Disasters can also entail what seems like the ordinary. "Everyone thinks about the big things and forgets about the little things that are more inclined to happen," says Parsons-Snyder. "The flu season in January and February can flood your ED [emergency department]. Ice storms can bring down power lines and electricity." The Department of Health and Human Services' (HHS) Office of the Assistant Secretary for Preparedness and Response (ASPR) in February 2018 published a fact sheet addressing risks related to patient surges from seasonal illness, such as flu.

Facilities must also prepare for events occurring nationally. If the hospital's two main risks from external disasters are hurricanes and vehicle accidents from a nearby highway, it must still prepare for the mass shootings and cyberattacks that increasingly dominate headlines. The year 2017 was one of the deadliest, with 345 mass shootings (defined as incidents in which at least four people are shot) taking place in the United States (Manella). Also in 2017, cyberattacks hit hospitals and health systems at a rate of more than one breach per day (Spitzer). Britain's National Health Service was the highest-profile victim of a worldwide ransomware attack last year that rendered the system's electronic patient records, phone lines, and emails inaccessible (Clarke and Youngstein).

Organizations must also consider their community's risk assessment and address those risks in its emergency plan. For example, if the area is vulnerable to wildfires, the plan should ensure that the facility is prepared to address risks from wildfires, including the need to evacuate.

Despite their efforts to conduct an HVA based on known risks, organizations must still prepare for the unexpected. "There's always something new and different," says Parsons-Snyder. Increasingly, for example, experts speculate that hospitals could be terrorism targets, causing long-term disruption of hospital operations (De Cauwer et al.).

The facility administrator at a Texas hospital forced to evacuate during Hurricane Harvey says, "You can't ever rest in the safety and assurance that things will go as expected, even if you've been through similar events. We write our plans . . . and everything on paper is mathematical and analytical. This storm threw that book out the window" (ASPR "When Hospitals Become Islands"). The hospital, Baptist Beaumont Hospital, evacuated when flooding in its community prevented it from bringing in supplies and personnel.

Emergency Operations Plan

The organization's emergency operations plan provides strategies to address the emergency events identified from the HVA. What business functions are essential to the facility's operations during an emergency? What staffing strategies are in place if staff shortages are expected? What backup measures are in place if information systems fail? How will the organization confirm the credentials of medical personnel who volunteer to help at the facility? What processes are in place if the facility expects a surge in additional patients during an emergency? How will the facility evacuate patients and staff? Is there a backup evacuation plan if nearby facilities are unable to receive patients? There are many more questions to address and, fortunately, ASPR provides healthcare emergency preparedness information for federal, state, and local governments and the private sector, including healthcare facilities.

For example, ASPR's Gap Analysis Tool can be used to identify gaps in the organization's emergency operations plan in light of the findings from the HVA and to prioritize those gaps. Its Health Care Preparedness and Response Capabilities guidance describes what the healthcare delivery system--hospitals, public health departments, emergency medical services, and others--have to do to effectively prepare for and respond to emergencies that impact the public's health.

The facility's emergency operations plan should be aligned with local, regional, and statewide emergency preparedness initiatives. Within the facility, all unit-level plans should be aligned with the organization's overall plan. CMS requires providers to review and update their emergency operations plan at least annually, taking into consideration, for example, lessons learned from events and drills from the previous 12-month period.

Along with the emergency plan, healthcare facilities must develop policies and procedures to support it. Like the plan, they should be reviewed and updated at least annually. Refer to What's in Your Policies? for some of the topics that CMS requires hospitals to cover in their emergency preparedness policies and procedures.

Community Networking

CMS's emergency preparedness rule emphasizes the need for community collaboration in disaster planning by requiring hospitals to a have a process to cooperate with local, tribal, regional, state, and federal emergency preparedness authorities to maintain an integrated response during an emergency. Hospitals must also document their efforts to contact emergency planning officials and their participation in collaborative planning.

"Coordination with peer hospitals and local disaster preparedness agencies is extremely important," says Parsons-Snyder. "If nothing else, they know who you are. A disaster is not the time to get to know each other."

As a hospital emergency preparedness coordinator, Parsons-Snyder participated in monthly meetings with other healthcare facilities and emergency planning authorities to discuss events in the area, address procedural issues, and develop working relationships. "We'd learn lessons from other organizations and go back to our facilities and look at what we were doing." Additionally, she participated in quarterly regional meetings of healthcare facilities and other groups that might be involved in an emergency, such as the department of health, law enforcement, and fire officials. "We'd share our hazard plans across the region," says Parsons-Snyder. "The networking was huge."

Networking among these various stakeholders has led to the emergence of formal healthcare coalitions to coordinate emergency preparedness for participating response organizations and healthcare facilities before, during, and after a disaster. When floodwaters from Hurricane Harvey inundated southeast Texas in 2017, the regional coalition oversaw the evacuation of 1,504 patients from 45 facilities in the region. Once the coalition's operations center was activated in an emergency, participating facilities functioned as regional entities, looking out for all hospitals in the area. (ASPR "Evacuating")

Communication

The CMS rule on emergency preparedness places a high priority on communication plans. After Hurricane Katrina struck the Gulf Coast in 2005, healthcare facilities from the area shared the challenges they faced when communication systems failed, Parsons-Snyder recalls. Emergency management officials from New Orleans came to her area to discuss lessons learned from the disaster. "They told us they lost the ability to make calls from the hospitals and would go to their cars to use OnStar," an emergency communication system, she says. "We brought their experiences back to our organizations to develop redundant systems for communication, using walkie-talkies, HAM [amateur radio] operators, and even courier services."

CMS requires hospitals to have communication plans that include contact information for staff, physicians, other hospitals and entities providing services under arrangement, volunteers, and relevant emergency preparedness officials. Additionally, the plans must describe primary and alternate means (e.g., pagers, cell and satellite phones, walkie-talkies, and amateur radio operators) to communicate with staff and emergency management officials, as well as methods to share patient information, as permitted by federal privacy rules, with other healthcare providers to maintain continuity of care.

Drills

Disaster drills enable healthcare facilities to test their emergency operations plan, analyze the results, and update the plan as needed. CMS requires organizations to conduct two exercises annually, including one community-based plan, unless a community exercise is unavailable. The second drill can be a full-scale drill or tabletop exercise, although the latter is not permitted for Joint Commission accreditation.

Drills also help the organization rehearse, so staff are familiar with their role during an actual disaster. A 2016 ransomware attack quickly paralyzed computer systems at the hospitals and outpatient centers of a Washington, DC-area health system. "We had never really rehearsed losing everything, much less all at once," says the director of the Institute for Public Health Emergency Readiness at the health system's MedStar Washington Hospital Center. "You need to exceed your comfort level to prepare for a problem this vast," he recommends. (ASPR "Lessons Learned")

Those who have experienced disasters remind hospitals to use drills to also test their evacuation plans. Reflecting on the experience last year of evacuating 122 patients from a Santa Rosa, California, hospital in three hours as wildfires approached, the assistant physician-in-chief for hospital operations at Kaiser Hospital Santa Rosa says that most of the hospital's drills had focused on surge scenarios, not evacuations. "None of us had actual experience evacuating a hospital . . . . (A) lot of improvisation occurred and lessons were learned," he says. (ASPR "The Last Stand")

Backup Systems

Events reported to ECRI Institute PSO highlight the vulnerability of utility systems to internal or external emergencies. Damage to power systems, for example, can render clinical and monitoring equipment inoperable, halt routine processes and procedures, and close operating rooms when heating and cooling systems fail.

Because emergencies can damage or destroy essential utility systems, healthcare organizations' emergency operations plan must address alternative means of providing them. Those utilities include the following:

• Electricity
• Water for consumption, for essential patient care activities, and for other purposes
• Fuel for building operations, generators, and essential transport services
• Medical gas and vacuum systems
• Heating and cooling systems or steam for sterilization

CMS does not specify that a generator is required to meet the "alternative sources of energy" requirement. However, most hospitals' emergency operations plans rely on backup generators to maintain emergency power. Whatever backup system is used, CMS says it must be properly installed, maintained, and routinely tested. Refer to Online Resources for more information on managing hospital emergency power systems.

Hospitals must determine how long they expect to remain open to care for patients and plan for their utilities accordingly. CMS requires healthcare facilities to implement emergency and standby power systems to sustain the subsistence needs of staff and patients, regardless of whether the facility decides to evacuate or shelter in place during an emergency. Subsistence needs include food, water, medical and pharmaceutical supplies, and alternate sources of energy to maintain the following:

• Temperatures to protect patient health and safety and sanitary storage of provisions
• Emergency lighting
• Fire detection, extinguishing, and alarm systems
• Sewage and waste disposal

As part of their effort to ensure emergency backup systems are in place, healthcare facilities must also periodically check the function of equipment batteries and backup batteries and emergency outlets connected to the facility's backup power supply.

The Next One

The great irony of the increased number of disasters is that each has helped to ensure that healthcare organizations are prepared for the next one. Experts analyze the experiences from severe disasters and share the lessons learned. "There are also valuable lessons that can be learned from an organization's emergency response, no matter how small," says Parsons-Snyder, reminding hospitals to include emergency response events in their event reporting systems to ensure continued learning from investigation and analysis.

Additional Materials

When Disaster Strikes: One Hospital's Experience

When Typhoon Soudelor struck Saipan, the largest island of the U.S. Commonwealth of the Northern Mariana Islands, the island's only hospital relied on its disaster readiness plan to serve its patients, staff, and community. Soudelor made landfall on Saipan on August 2, 2015, and was the worst storm to hit Saipan in nearly 30 years, leaving hundreds of homes damaged or destroyed and residents without power or water. "It was the worst I've ever seen," says Esther Muna, chief executive officer of Commonwealth Healthcare Corporation (CHC), which operates the island's hospital.

Although the typhoon was not on track to hit Saipan, it shifted course and gained in intensity as it made landfall on Saipan with sustained winds of 130 miles per hour (mph) and gusts of 160 mph. Before Soudelor made landfall, CHC had activated its incident command center "to prepare and to notify staff that they may be needed," says Warren F. Villagomez, CHC's program director of public health/hospital emergency preparedness. For the next few days, Muna and Villagomez remained at the hospital 24 hours a day.

Damage to the facility was limited. "We cleaned up the debris, and we were functional the next day," says Villagomez. With the majority of the island without electricity, CHC's hospital was operating on its generator. The hospital relied solely on its generator for power for about 1½ weeks after the storm. That experience reminded Muna of the importance of ongoing generator maintenance and testing. Deferring generator maintenance "is not an option," she says. "The generator is critical. When a storm comes on the island, we need to be ready."

Even after power was restored to the hospital, electricity was still unstable, so the hospital continued to use its generator. "We needed stable power for critical life support," says Villagomez, and to power the well pumps, which were supplying water for everything from staff showers to patient dialysis.

Some staff and volunteers had no place to go, so the hospital converted offices into living spaces to accommodate them. "If we couldn't care for them, we'd be hurting ourselves," says Muna.

“We had to adjust along the way," she says. For example, without available gas supplies on the island, the hospital used its vans to transport staff from their homes to the hospital. “They had no other way to get to work," says Muna.

"We were the main resource for people on the island," says Muna. Before the storm, the hospital had instructed individuals who needed access to power for oxygen and medical equipment and women who were close to delivery to stay at the hospital to ensure continuity of care. Some island residents remained at the hospital because they did not have any power in their homes. In some situations, the hospital found generators for residents staying at the hospital so they could return to their homes.

Throughout the island's recovery, the hospital deployed staff to the community to treat issues that could be handled on an outpatient basis and to prevent unnecessary admissions. "We had to make sure the hospital was not inundated," says Muna. For example, outreach staff treated high blood pressure and wounds, provided medications, administered vaccines, and provided crisis counseling. "We were trying to avoid a strain on our emergency department and hospital by providing treatment, preventive care, and medication to the community. If that system failed, we knew it would come back to our hospital," she says.

To CHC's advantage, the island's health services, such as community health centers and dialysis services, are operated by the system. "That's the advantage of having public health under one roof. We were able to make decisions autonomously," says Muna.

Nevertheless, CHC's ongoing partnerships with other agencies helped to ensure its success in recovering from Soudelor. "We have coalition meetings and tabletop exercises and share information about our services," says Villagomez.  "Alignment with our key partners--public health, volunteer management, and other government agencies—was key. We train with the fire department, airport, mayor's office, private clinics, volunteers, and even the media." These partnerships ensure that CHC's staff know and trust their partners in disaster response and recovery. "They trusted us and we trusted them," he says.