What's a Lab to Do During and After a Hurricane?

Fred Rodriguez; Rajeevan Selvaratnam; Peggy Mann; Rina Kalariya; John R. Petersen

Disclosures

Lab Med. 2018;49(2):e23-e28. 

In This Article

Abstract and Introduction

Abstract

Although laboratories may be able to rely on a comprehensive Hurricane Plan during a hurricane, alarming and unanticipated events frequently occur. To minimize disruption of lab operations, it is important to try to mitigate the impact of these unexpected events as quickly as possible, in the quest to minimize negative outcomes. In this article, we discuss approaches to dealing with unanticipated events during and after hurricanes, based on our personal experiences.

Introduction

When a predicted hurricane approaches, hopefully the laboratory has prepared and practiced carrying out a Hurricane Plan that addresses all the risks anticipated to occur during the storm. This prestorm risk assessment (which was discussed in a previous paper for Lab Medicine) is critical to comprehensive preparation for a storm. As climate change brings storms of unprecedented increasing intensity (eg, Hurricanes Harvey and Irma of 2017 and the Bomb Cyclone [a type of wintertime hurricane] of January 2018), a functioning lab remains crucial to hospital operations. However, as the old Army cliché states, "every plan is perfect until the first shot is fired." In almost every storm, unanticipated events can and do occur (air conditioning/ventilation failure, power failures, flooding, structural damage, etc). Thus, to maintain lab operations to the fullest extent possible during and after the storm, labs must be prepared to make adjustments and modifications to the plan as the situation warrants.

Although the focus of this article is on precautions and mitigating actions to take during and after a hurricane, the content is relevant to any weather event or other disaster (tornadoes, floods, etc). The National Oceanic and Atmospheric Administration (NOAA) defines hurricanes, typhoons, and cyclones as similar weather phenomena and assigns names to these phenomena depending on the location at which the storm originates.[1]

During the storm, a change in the status of any of the elements discussed in the following paragraphs, such as communication, staffing, transportation, supplies, etc, can adversely impact lab operations. If possible, mitigation of the change in status should be made during the storm, with the hope of maintaining as much lab functionality as possible. If mitigating actions are impossible during the storm, modifications to lab operations must be made as soon as feasible. It is critical to communicate any changes in lab operations in a timely manner to the facility administration and clinical staff who are riding out the storm (staying onsite to deal with the storm), as well as to offsite personnel. The following are essential elements of lab functions that are subject to modifications and changes.

Elements of critical functions during and after the storm:

A. Communication

   1) Communication of laboratory status between the administration and clinical staff, whether on- or offsite, is essential through all phases of the storm (before, during, and after). This includes communication on reduction of or modifications to the lab test menu during or after the storm.

   2) Before hurricane landfall, each hospital in the affected zone should set up an Incident Command Center (ICC)[2,3] as designated by the Health System Emergency Plan. The ICC integrates facilities, equipment, personnel, procedures, and communications operating within the organizational structure.

   3) Establishment of communication with key offsite lab staff is also important, to coordinate relief and/or rescue efforts.

   4) Hospital departments, including the Clinical Laboratory and Department of Pathology, should continue to operate or to evacuate all personnel and shut down operations, based on the ICC decisions going into, during, or even after the hurricane incident.

   5) Discontinuing pickups from offsite specimen collection stations requires communication with clients and courier drivers, to avoid delays or cancellation of lab tests.

   6) If a telephone or information technology (IT) system failure occurs during or after the storm, manual backup procedures will need to be implemented to mitigate the failure.

   7) Team huddles (strategic check-in meetings among staff members) should be carried out at defined intervals (at minimum, every 24 hours) or more frequently, as warranted by weather conditions.

B. Assessment of lab status includes evaluation of the following key elements:

   1) Staffing

      a) The lab needs to report the status of the staff (ie, the ride-out team) to the ICC before, during, and after the storm. Short staffing (the failure of staff to report for duty or the compromising of staff on duty due to illness, injury, or fatigue) may have to be mitigated by reducing or eliminating the availability of some lab tests or services.

      b) Without appropriate staffing and with uncertainty in proper instrument function, the potential for hampering patient safety though medical errors is likely higher during and after the effects of a hurricane. The situation may be made worse by compromise of functionality in other hospital departments. For example, health information services, which during normal operations help reduce diagnostic errors by facilitating timely and easy access to information,[4] may be compromised by the effects of the storm. Thus, the staffing assessment will need to account for assignment of duties to those personnel who are competent or trained in manual processes.

      c) By providing appropriate accommodations and emotional support, staff hunger, sleep deprivation, and fatigue should be mitigated. Employees could experience anxiety and stress if outside phone or Internet contact with loved ones fails during the time they are on duty and those employees are unable to leave the premises. Having disaster behavioral health teams available to staff also mitigates health consequences by providing early psychological interventions.[5]

      d) The onsite ride-out and recovery team staff members should be advised to bring extra clothing, blankets, sleeping bags, toiletries, phone chargers, essential medications, etc, and any other personal comfort items when reporting for duty.

   2) Preanalytic issues

      a) The impact on lab operations due to the compromise of order entry; test menu; specimen acquisition, transport, integrity, and storage; and other functions as a result of the storm must be reported to the ICC.

      b) If such compromise in preanalytic functions occurs, measures and communications are needed to ensure timely delivery of specimens. It is also essential to ensure that test orders are communicated appropriately (eg, paper based requisition forms of the storm test menu should be readily available, with the option to checkmark the names of the tests requested [vs writing in the needed test, which is more error prone]).

      c) Documentation is also critical during this time, especially if the hospital is without computerized physician order entry (CPOE) and/or the laboratory information system (LIS). Downtime systems need to be in place, and copies of the order requisition for each lab order should be kept for documentation purposes and for the later reporting of results in the electronic medical record.

      d) In the case of insufficient specimen volume or specimens in which the integrity is compromised, a request for a replacement specimen should be made promptly or at the discretion of the Laboratory Medical Director, the attending physician, or hospital policy addressing the report of the limited test result(s), with appropriate explanatory comments appended.

      e) As conditions allow, there needs to be assessment to sustain or discontinue courier and driver specimen pickup services.

   3) Analytic issues

      a) The ICC must also be informed of the functionality of lab instruments and the lab staff. This includes compromise of air conditioning and ventilation systems that affect instrument function, power failures, loss of water systems, loss of information systems, and other failures that could adversely impact lab operations.

      b) Analytically, not all testing options may be available. It has been reported[6] that approximately 2% of clinical-lab test codes account for approximately 80% of testing volume. Those lab tests that are essential to patient care, which the lab staff would be expected to perform during a hurricane event, must be determined in collaboration with the clinical lab medical director and physicians from various disciplines. A starting point of essential testing (ie, Essential Diagnostics) may include testing to complement and monitor the safe use of the World Health Organization (WHO) Model List of Essential of Medicine.[7,8] Ultimately, the lab needs to ensure that the appropriate tests offered routinely are prioritized based on need and availability, with additional supplemental testing requiring additional justification as the need arises.

      c) The ideal situation is that instruments in service are analytically sound and have undergone preventative maintenance, necessary tune-ups, and scheduled services in advance. However, despite these services and maintenance, one can always expect some level of instrument unpredictability. In this case, having a duplicate instrument set up helps; some attention can be diverted to troubleshooting the problematic instrument, which may include referring to the untouched troubleshooting or operator manual. However, if one instrument stops working, a backup instrument must have the reliability to pick up the workload. In such cases, duplicate instruments will need to be mirrored with an identical test menu, which may not be the case under normal circumstances.

   4) Postanalytic issues

      a) The timely and efficient reporting of test results could also be compromised by hurricane events (eg, loss of the IT system). Courier delivery of paper based copies of test results may be impractical but might be the only option available to mitigate loss of the IT system. Without a functioning LIS, automated reflex testing in the postanalytical phase will not be triggered, such as the processes of testing certain infectious diseases. In such cases, staff members need to be prepared to perform any additional testing.

      b) If calculated results such as anion gap or globulin fractions are typically provided, how would one do so if the IT system were unavailable? This process may be easier if the instrument or functioning middleware performs the calculation. However, downtime in IT operation may necessitate alternatives, such as manual calculation with consistent and appropriate reference intervals, to interpret test results in a meaningful manner.[9] If reference intervals have placeholders in instruments and middleware, in addition to the IT system, it is essential to have consistent and updated reference intervals across the entire process to print out records consistently (in case the IT system is nonfunctional).

      c) Documentation is also critical during this time, especially for a hospital without an LIS. For example, it is important to postanalytically document the time that results are sent to the health care provider, including the employee number and/or the name of the health care provider receiving the result. One must have a copy of the documentation of the result sent to the lab and another copy sent to the patient location.

   5) Reagents and supplies inventory (including blood components, if there is a blood bank)

      a) The ICC must be informed of the status of reagents and supplies (including blood components). This may include the extension of blood component expiration dating if the onsite blood products cannot be replenished.

      b) If the Emergency Plan calls for the additional use of point-of-care testing (POCT; expanding the menu or adding additional testing locations), instruments and reagents are dispensed/distributed at this time. An insufficient onsite inventory or amount of reagents and supplies for any instrument platform could potentially compromise lab operations.

   6) What issues should one anticipate after the storm?

      A. Resuming and maintaining communication with offsite key staff and other resource personnel (eg, instrument vendors) is essential.

      B. Management should also anticipate transportation requirements for ferrying onsite staff to their respective homes and returning offsite staff members to duty on an individual basis. However, such transportation would depend on the severity (intensity) of the storm and the distance from landfall that the employees live. In the event that the impacted communities shut down public and private schools and daycare facilities, additional staff members may be unable to return to work until normalcy returns to their community. Employees would also be concerned about elderly parents or family members living at home or in full-time residential facilities. Employees who are forced to relocate to other housing due to flooding or wind damage may have to deal with considerably increased travel time to work. Also, travel routes typically used and public transportation may be compromised.

      C. Rescue (evacuations of staff are conducted as arranged through the ICC)

         1) If the lab is nonfunctional and must be abandoned, the staff and administrators much communicate needs for rescue with the ICC, offsite key staff, and other resource personnel to assure safe removal of the onsite staff.

         2) Accomplish rescue as soon as possible.

         3) Assist onsite staff members in contacting relatives and friends to report their safe rescue.

      D. Ensure procurement or restocking of reagents and other supplies in a timely manner to sustain lab operations. Sometimes, the storm could also impact existing operations of vendors, resulting in back order or delayed delivery of reagents and/or supplies. To overcome such a situation, alternative vendors must be contacted in a timely manner.

   7) Recovery

      A. First, if (or when) the lab can be occupied, staff members that had been offsite must relieve those that are onsite (ie, the ride-out team).

      B. Staff members should be given the proper credentials to reenter the facility, in case safety/security parameters have been set up to deter looting and criminal activity within the disaster zone.

      C. Repair any damage caused by the storm (structural damage, utilities, instrumentation, etc).

      D. Assess and prioritize sequential resumption of core operations disrupted by the storm (preanalytic, analytic, postanalytic).

      E. Locate and bring back offsite staff members displaced by the storm.

      F. If lab operations cannot be resumed, implement a plan to refer (send out) lab testing to other labs that were not affected by the storm (ie, other labs within the same hospital system or commercial labs) until lab operations can be restored.

   8) Restoration is eventually accomplished by progressive resumption of all prestorm operations.

   9) Some specific examples from our experiences of unexpected events and their consequences during a storm are as follows:

      A. During Hurricane Katrina (August 2005), initially, the air conditioning and ventilation systems failed, which raised ambient temperatures in the lab and caused analytic instrumentation shutdown. The only testing that could be continued was on temperature independent chemistry platforms, such as some POCT tests and urinalysis.

      B. During Hurricane Katrina, when all electrical service to the facility failed due to the massive flooding of New Orleans, LA (ie, the street outside the hospital had water as deep as 4 feet), evacuation from the hospital was the only option. Only at 5 days after the storm could military vehicles reach the hospital to evacuate patients and staff to Baton Rouge, LA. (Note: a replacement hospital was built, which included elevation above the first floor of all utilities required to maintain viable continued operations, but the new hospital was not functional until 2017.)

      C. During Hurricane Ike (September 2008), generators at The University of Texas Medical Branch (UTMB Health) Galveston campus failed due to saltwater flooding. This occurrence prompted evacuation of all UTMB Health essential clinical lab staff on the Galveston campus to Austin, TX. Mitigating actions during and immediately after the storm were impossible due to flooding. However, subsequent mitigating actions included structural modification of hospital buildings to elevate all utilities above the first floor to ensure uninterrupted operations, adding flood walls around the campus building that houses multiple clinics, renovating first floor corridors with tile flooring and walls, and raising power outlets as high as 3 to 4 feet above floor level.

      After Hurricane Ike, clinical lab functions did not resume for weeks. All health care buildings on the Galveston campus were closed due to flooding and then due to the consequent repairs and restoration.[10] No patient care resumed in the hospital or clinics for weeks to months. Providers could not see patients unless they came off Galveston Island to share space in existing or expanding/new practices set up after Ike. In addition to adding POCT as appropriate, commercial reference lab accounts had to be set up quickly by the Clinics Administration to continue diagnostic lab testing services.

      More recently (August 2017), massive flooding due to Hurricane Harvey did not impact the physical structures of the 3 UTMB Health campuses and the campus, but some offsite clinics were affected. However, the flooding stopped the employees staffing the lab from being relieved to return home immediately after the storm. This happened because offsite employees who lived on the mainland could not immediately return to work on the Galveston Island campus or the 2 campuses located on the mainland. The highway connecting Houston, TX to Galveston, which is the main courier route between the 2 mainland campuses, with the main clinical lab located in Galveston, was flooded and impassable for several days. Other mainland courier routes also flooded, so alternatives schedules and routes had to be changed accordingly. Although only 2 mainland clinics had to be relocated due to flooding, disruption of lab services happened regarding of courier service. Fourteen routes had to be canceled, which affected 45 Fleet Transit–serviced clinics. These cancellations and delays in service involved 11 correctional managed care specimen collection labs, 6 teen clinics, and 2 home health clinics. Fleet Transit delivers not only 7000 specimens daily but also supplies, materials, and medical sterilized instruments. The company also provides mail delivery support to remote sites and 3 campuses. It is estimated that business disruption from Hurricane Harvey flooding took place during a period of 11 to 15 days.

      D. During Hurricane Irma (September 2017), the electrical grid on which Morton Plant North Bay Hospital in New Port Richey, FL was situated was shut down, given that the hospital was also within the evacuation zone and that the city of New Port Richey forecasted the area to be hit with 5-foot storm surges. Because the labs were on the ground floor, the necessary actions to take were precautionary measures and evacuation: the hospital would not be functional with power generators at ground level.

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