Rebuilding Emergency Care After Hurricane Sandy

When disasters strike the emergency department: a case series and narrative review

INTRODUCTION

Emergency departments (EDs) are reasonably well prepared for external disasters, such as natural disasters, mass casualty incidents, and terrorist attacks. However, crises and disasters that emerge and unfold within hospitals appear to be more common than external events. EDs are often affected. Internal hospital crises and disasters (IHCDs) have the potential to endanger patients, staff, and visitors, and to undermine the integrity of the facility as a steward of public health and safety. Furthermore, ED patient safety and logistics may be seriously hampered.

METHODS

Case series of 3 disasters within EDs. Narrative overview of the current IHCD-related literature retrieved from searches of PubMed databases, hand searches, and authoritative texts.

DISCUSSION

The causes of IHCDs are multifaceted and an internal disaster is often the result of a cascade of events. They may or may not be associated with a community-wide event. Examples include fires, floods, power outages, structural damage, information and communication technology (ICT) failures, and cyberattacks. EDs are particularly at-risk. While acute-onset disasters have immediate consequences for acute care services, epidemics and pandemics are threats that can have long-term sequelae.

CONCLUSIONS

Hospitals and their EDs are at-risk for crises and their potential escalation to hospital disasters. Emerging risks due to climate-related emergencies, infectious disease outbreaks, terrorism, and cyberattacks pose particular threats. If a hospital is not prepared for IHCDs, it undermines the capacity of administration and staff to safeguard the safety of patients. Therefore, hospitals and their EDs must check and where necessary enhance their preparedness for these contingencies.

Hospitals Providing Temporary Emergency Department Services in Alternative Care Settings After Hurricane Sandy

This article reports findings of a qualitative study describing how the US Department of Veterans Affairs cared for vulnerable veterans after Hurricane Sandy while medical center was closed for an extended period. This experience highlights how vulnerable patients continued to need care. Hospital preparedness planning efforts focus primarily on sheltering in place and evacuation. Research is needed to identify how hospitals provided temporary emergency services in alternative settings to inform practical guidance. Hospital planners should anticipate that their most vulnerable patients will continue to need emergency care. Viable solutions should be considered to meet immediate and long-term patient needs.

Freestanding Emergency Critical Care During the Aftermath of Hurricane Sandy: Implications for Disaster Preparedness and Response

OBJECTIVE

To assess the impact of an emergency intensive care unit (EICU) established concomitantly with a freestanding emergency department (ED) during the aftermath of Hurricane Sandy.

METHODS

We retrospectively reviewed records of all patients in Bellevue's EICU from freestanding ED opening (December 10, 2012) until hospital inpatient reopening (February 7, 2013). Temporal and clinical data, and disposition upon EICU arrival, and ultimate disposition were evaluated.

RESULTS

Two hundred twenty-seven patients utilized the EICU, representing approximately 1.8% of freestanding ED patients. Ambulance arrival occurred in 31.6% of all EICU patients. Median length of stay was 11.55 hours; this was significantly longer for patients requiring airborne isolation (25.60 versus 11.37 hours, P<0.0001 by Wilcoxon rank sum test). After stabilization and treatment, 39% of EICU patients had an improvement in their disposition status (P<0.0001 by Wilcoxon signed rank test); upon interhospital transfer, the absolute proportion of patients requiring ICU and SDU resources decreased from 37.8% to 27.1% and from 22.2% to 2.7%, respectively.

CONCLUSIONS

An EICU attached to a freestanding ED achieved significant reductions in resource-intensive medical care. Flexible, adaptable care systems should be explored for implementation in disaster response. (Disaster Med Public Health Preparedness. 2016;10:496-502).

Spatial Shift in the Utilization of Mental Health Services After Hurricane Sandy Among New York City Residents Enrolled in Medicaid

Objective

Closure of several New York City (NYC) hospitals after Hurricane Sandy caused an unanticipated, extended surge in patient demand at open hospitals. This study identified hospitals with a significant increase in mental-health-related emergency department, inpatient, and outpatient visits from Medicaid patients displaced by Hurricane Sandy.

Methods

NYC Medicaid patients were classified into non-mutually-exclusive geographic categories corresponding to residence in areas served by Bellevue Hospital Center and Coney Island Hospital, the hurricane impact area, and all of NYC. For each geographic region, we compared the observed to the expected number of service visits in the 6 months after the storm. The expected number of visits was calculated from 2-year trends in mental health claims.

Results

Twenty-four facilities in all 5 NYC boroughs experienced patient redistribution from storm-affected areas. Eighteen facilities had a concurrent surge in total Medicaid patients, which suggested that redistribution had a greater impact on resource use at these locations.

Conclusions

The redistribution of Medicaid patients after Hurricane Sandy increased mental health service utilization at facilities not near flooded areas. Our findings can aid in surge capacity planning and thereby improve the continuity of mental health care after a natural disaster. (Disaster Med Public Health Preparedness. 2016;10:420–427)

Observation Services Linked With an Urgent Care Center in the Absence of an Emergency Department: An Innovative Mechanism to Initiate Efficient Health Care Delivery in the Aftermath of a Natural Disaster

Objective

The emergency department (ED) of NYU Langone Medical Center was destroyed by Hurricane Sandy, contributing to a public health disaster in New York City. We evaluated hospital-based acute care provided through the establishment of an urgent care center with an associated ED-run observation service (EDOS) that operated in the absence of an ED during this disaster.

Methods

We conducted a retrospective cohort study of all patients placed in an EDOS following a visit to an urgent care center during the 18 months of ED closure. We reviewed diagnoses, clinical protocols, selection criteria, and performance metrics.

Results

Of 55,723 urgent care center visits, 15,498 patients were hospitalized, and 3167 of all hospitalized patients (20.4%) were placed in the EDOS. A total of 2660 EDOS patients (84%) were discharged from the EDOS. The 8 most frequently utilized clinical protocols accounted for 76% of the EDOS volume.

Conclusions

A diverse group of patients presenting to an urgent care center following the destruction of an ED by natural disaster can be cared for in an EDOS, regardless of association with a physical ED. An urgent care center with an associated EDOS can be implemented to provide patient care in a disaster situation. This may be useful when existing ED or hospital resources are compromised. (Disaster Med Public Health Preparedness. 2016;10:405–410)

Geographic Distribution of Disaster-Specific Emergency Department Use After Hurricane Sandy in New York City

Objective

We aimed to characterize the geographic distribution of post-Hurricane Sandy emergency department use in administrative flood evacuation zones of New York City.

Methods

Using emergency claims data, we identified significant deviations in emergency department use after Hurricane Sandy. Using time-series analysis, we analyzed the frequency of visits for specific conditions and comorbidities to identify medically vulnerable populations who developed acute postdisaster medical needs.

Results

We found statistically significant decreases in overall post-Sandy emergency department use in New York City but increased utilization in the most vulnerable evacuation zone. In addition to dialysis- and ventilator-dependent patients, we identified that patients who were elderly or homeless or who had diabetes, dementia, cardiac conditions, limitations in mobility, or drug dependence were more likely to visit emergency departments after Hurricane Sandy. Furthermore, patients were more likely to develop drug-resistant infections, require isolation, and present for hypothermia, environmental exposures, or administrative reasons.

Conclusions

Our study identified high-risk populations who developed acute medical and social needs in specific geographic areas after Hurricane Sandy. Our findings can inform coherent and targeted responses to disasters. Early identification of medically vulnerable populations can help to map “hot spots” requiring additional medical and social attention and prioritize resources for areas most impacted by disasters. (Disaster Med Public Health Preparedness. 2016;10:351–361)

Acute post-disaster medical needs of patients with diabetes: emergency department use in New York City by diabetic adults after Hurricane Sandy

OBJECTIVE

To evaluate the acute impact of disasters on diabetic patients, we performed a geospatial analysis of emergency department (ED) use by New York City diabetic adults in the week after Hurricane Sandy.

RESEARCH DESIGN AND METHODS

Using an all-payer claims database, we retrospectively analyzed the demographics, insurance status, and medical comorbidities of post-disaster ED patients with diabetes who lived in the most geographically vulnerable areas. We compared the patterns of ED use among diabetic adults in the first week after Hurricane Sandy's landfall to utilization before the disaster in 2012.

RESULTS

In the highest level evacuation zone in New York City, postdisaster increases in ED visits for a primary or secondary diagnosis of diabetes were attributable to a significantly higher proportion of Medicare patients. Emergency visits for a primary diagnosis of diabetes had an increased frequency of certain comorbidities, including hypertension, recent procedure, and chronic skin ulcers. Patients with a history of diabetes visited EDs in increased numbers after Hurricane Sandy for a primary diagnosis of myocardial infarction, prescription refills, drug dependence, dialysis, among other conditions.

CONCLUSIONS

We found that diabetic adults aged 65 years and older are especially at risk for requiring postdisaster emergency care compared to other vulnerable populations. Our findings also suggest that there is a need to support diabetic adults particularly in the week after a disaster by ensuring access to medications, aftercare for patients who had a recent procedure, and optimize their cardiovascular health to reduce the risk of heart attacks.

Redistribution of Emergency Department Patients After Disaster-Related Closures of a Public Versus Private Hospital in New York City

Sudden hospital closures displace patients from usual sources of care and force them to access facilities that lack their prior medical records. For patients with complex needs and for nearby hospitals already strained by high volume, disaster-related hospital closures induce a public health emergency. Our objective was to analyze responses of patients from public versus private emergency departments after closure of their usual hospital after Hurricane Sandy. Using a statewide database of emergency visits, we followed patients with an established pattern of accessing 1 of 2 hospitals that closed after Hurricane Sandy: Bellevue Hospital Center and NYU Langone Medical Center. We determined how these patients redistributed for emergency care after the storm. We found that proximity strongly predicted patient redistribution to nearby open hospitals. However, for patients from the closed public hospital, this redistribution was also influenced by hospital ownership, because patients redistributed to other public hospitals at rates higher than expected by proximity alone. This differential response to hospital closures demonstrates significant differences in how public and private patients respond to changes in health care access during disasters. Public health response must consider these differences to meet the needs of all patients affected by disasters and other public health emergencies.