Hurricanes test radiology's disaster preparedness

When disaster strikes in the U.S., municipal infrastructure services are expected to remain intact or to be rapidly restored. Residents in affected areas count on the availability of water, power, sewage systems, police protection, and emergency healthcare services. Prolonged lack of these core services evokes shock, no matter how severe the disaster that caused them to fail.

The devastation caused by Hurricane Katrina, exacerbated by the slow and often ineffective response of the federal and state governments, and some local governments, shook the nation.

Americans expect hospitals to be fortresses of invulnerability that will perform despite any disaster. Hospitals take this mandate seriously; disaster planning is an intrinsic element of their operations. With this in mind, Diagnostic Imaging investigated the impact of Hurricanes Katrina and Rita on radiology departments and imaging centers, focusing on three key questions:

- What preparations did radiology departments and imaging centers take to protect themselves against an impending natural disaster and how well did these preparations work?

- How robust are digital radiology patient records?

- How were radiology department operations affected after the storm?

What we found:

- Hospitals deliberately designed and built to withstand the effects of windstorms and floods survived remarkably well. Few hospitals, however, are prepared to function for lengthy periods of time without municipal water and electricity.

- The lessons of prior natural disasters, particularly hurricanes, have been applied. Hospitals are equipped to provide emergency power, water, medicine, food, linens, and supplies for three to five days.

- Healthcare professionals are dedicated, innovative, and resilient in situations of high stress and extraordinary circumstances, as are many local vendor staff.

- Some radiology vendors reacted faster than government agencies. They mobilized and delivered equipment, supplies, and assistance that exceeded the scope of their business obligations.

- The conversion from paper records and x-ray film to digital saved medical records that otherwise would have been destroyed.

- Hurricane Katrina will change hospital operations. Radiology departments that are not yet digital may escalate the conversion process.

PREPARING FOR THE WORST

Hospitals located along the coastline of the Gulf of Mexico have developed comprehensive disaster preparedness plans, which are reviewed regularly and modified as needed. Most staff are hurricane veterans who know what to expect and what is expected of them. Hospitals begin to implement the early stages of disaster plans at the first notification of an intense storm.

"If you are shaking dust off your plans even at first warning of a potential situation, you're starting off in deep trouble," said Michael West, diagnostic imaging director at Memorial Hospital in Gulfport, MS.

The greatest liability in a filmless hospital is loss of power, said Dr. Kevin W. McEnery, deputy division head for informatics at the University of Texas M.D. Anderson Cancer Center in Houston.

"Servers that supply key components of the hospital must be kept powered. Power is also needed in the closets where the network switches are located," he said. "It is important to verify that these actually work with 'red plug' power."

The more emergency power capacity available, the more effectively a hospital will function. The VA Gulf Coast Veterans Health Care System in Biloxi learned that lesson from Hurricane Georges in 1998, said David Massey, PACS administrator.

"After that experience, we purchased two building-sized emergency generators with a huge amount of diesel fuel capacity. We never lost power, and we always had air conditioning during and after Katrina," Massey said.

Touro Infirmary in New Orleans had enough diesel fuel for "normal" hurricane conditions lasting 24 to 48 hours. But in view of the magnitude of Hurricane Katrina, the facility limited generator use, said Kim Keene, vice president. As a result, diagnostic imaging services were reduced to a bare minimum.

Hospitals should be prepared for generator malfunction. The Ochsner Clinic in New Orleans had three generators working at the start of Hurricane Katrina, but within hours, one was literally blown away and another's circuit board burned up. Replacement parts were not available, nor were service personnel onsite to restore the second generator.

Daryl Thompson, PACS administrator of Singing River Hospital in Pascagoula, MS, recommends that the PACS administrator work closely with the IT department to identify which critical components of the RIS, PACS, and dictation system need power and how much power emergency generators will have to provide. Those key components should be located in watertight places.

Requirements are sometimes inadvertently overlooked, Thompson said. Ochsner discovered on the day Katrina struck that none of its diagnostic reading rooms had red plug power.

EARLY REACTION

The RIS and digital dictation systems at Memorial Hospital Gulfport were located in a computer room on the fifth floor that had hurricane-wind-resistant windows. Nonetheless, the wind gusts of the Category 4 storm blew out a window and entered the computer room, damaging some servers.

Water seeping into a building through a damaged roof can travel anywhere. After the rubber coating of the Ochsner Clinic's roof ripped off, water began flowing down the walls. The entire radiology department team mobilized, covering up computers, electronic equipment, and imaging systems with garbage bags and plastic sheeting, said Suzanne Young, administrative director of radiology.

"Water was coming in everywhere. We used a crowbar to poke holes in strategically located ceiling tiles under which we placed buckets so that the ceilings would not collapse. We knew that water would ruin the equipment," Young said.

It is important to identify the minimal components of a PACS that need to function and to prepare to make both prestorm and on-the-fly routing changes. RIS and PACS vendors suggest that customers consult with their vendors to develop easy-to-understand instructions. When the Ochsner Clinic had to shut down its servers during the storm, it was able to reach its PACS vendor's service engineers by telephone. They helped the staff reroute the system so that the available modalities transmitted images directly to two diagnostic workstations.

PACS vendors also recommend that members of the disaster team know how to shut down a system. Customers with large, complex systems should appoint a PACS administrator as an onsite member of the disaster team.

Bob Lindekens, a veteran Gulf Coast account executive for Agfa Healthcare, advises that during an emergency, radiology departments shut down and unplug all equipment that drains power even in the "off" configuration. Facilities with PACS should ensure that images can be printed directly from the modalities that will be run on emergency power and that they have an ample supply of film to meet printing needs.

Gulfport's Memorial Hospital had to shut down its PACS server twice, due to power fluctuations that compromised the chillers' ability to maintain the necessary air conditioning. West had to close down and restart the servers himself because the PACS administrator was not part of the hospital's hurricane team. The first time he took the system down, he had telephone support from his PACS administrator and the PACS vendor's help desk. The second time, with no communication to the outside world, he was on his own with the operator's manual.

Because the Ochsner Clinic lost two-thirds of its power capability a few hours after the storm struck, the temperature in the third floor computer room rose rapidly, ultimately reaching 114 degrees.

"We had no choice but to shut down the servers on the day of the storm," said Susan Ortiz, RIS team leader. "We went into downtime protocol for RIS and PACS immediately, something we didn't anticipate we would be doing so soon."

Singing River Hospital pumped water from a lake near the hospital entrance into the hospital's cooling system and succeeded in keeping its computer room cool.

PROTECTING MRI SYSTEMS

Hurricanes Katrina and Rita proved that all modalities and computer equipment are extremely vulnerable to extended exposure to high heat, humidity, and water. James Hitzman, director of diagnostics at Touro Infirmary, reports that although nuclear medicine equipment was raised several feet off the floor to protect it from flooding, several weeks without power and air conditioning led to rusted electronic components of the gamma camera, portable nuclear camera, and radiography/fluoroscopy system.

For both financial and safety reasons, protecting an MR scanner from quenching is critical. Emergency power should be supplied to an MR system's cold head vacuum pump, and the room containing the magnet must be watertight, said Tobias Gilk of Junk Architects in Kansas City, MO, a firm that specializes in the design of MRI facilities.

David Robinson, technical director of Diagnostic Imaging Services, a chain of five Louisiana imaging centers, recommends filling the magnets with cryogen before predictable storm seasons. He also suggests raising the coils of a magnet and anything else that can be water damaged, such as control consoles, and inspecting the MRI quench duct.

The Touro Infirmary ramped down its MRI and moved everything in the room close to the magnet to protect it. The cryogen level of the magnet decreased by 5%, and Hitzman was surprised that it did not quench.

When the Ochsner Clinic lost most of its power, the radiology department knew the level of helium in each of its three MRI systems, Young said.

"The systems that show the helium levels run off power, and we suddenly didn't have much of that. So we had to be creative, using extension cords to get power to the system that monitors helium," she said. "When the city government made a radio announcement that a nine-foot-high wall of water was heading our way, we knew we would run low on helium, and we had no way of getting chilled water to the units. Our concern was that floodwaters would cause all three units to quench simultaneously, and we were fearful of the destruction such an event could cause."

With the assistance of a radiologist and a manager holding a flashlight, Young quenched the magnets. The city government's radio announcement did not prove true for Ochsner's neighborhood; unlike other hospitals in New Orleans, the clinic never flooded.

GE Healthcare delivered a portable MRI during the post-storm week. A GE representative reported that it took almost three weeks to recover the 1.5T magnet. The second 1.5T magnet was still in the recovery process as of mid-October, and no timeline had been established for bringing up the third.

PACS BACKUP AND OFFSITE STORAGE

Most of the hospitals and imaging centers in Louisiana, Mississippi, and Texas whose staff members were interviewed for this article survived the storm with their information systems 100% intact and fully operational when normal operations resumed. At New Orleans' Memorial Medical Center and Lindy Boggs Medical Center, staff wearing hazardous material body suits and respirators took on the laborious task of retrieving film and other medical records.

Radiology departments that had converted to digital were at an advantage.

"No matter what happens to the hardware, patient records in a RIS and PACS are not going to be destroyed. Unlike our old film libraries, as long as a PACS is properly backed up, we don't have to worry," West said.

RIS and PACS administrators backed up systems to the time of hospital lockdown and took duplicate tapes to safe locations outside the hospital. For Stephen Gaines, administrative director of radiology of the University of Texas Medical Branch at Galveston, this meant transporting the tapes from Galveston Island to another UTMB facility on the mainland.

PACS service engineers arrived onsite to assist with ramp-downs and startups. Several offered to stay onsite with the storm team. Others provided extended telephone assistance.

As of October, no permanently destroyed digital records had been identified. At Hancock Medical Center in Bay St. Louis, MS, which was severely damaged by the storm surge, backup files remained intact even though the newly installed PACS was destroyed.

The New Orleans VA Medical Center was permanently evacuated. The basement of the 354-bed hospital was flooded, and water lapped at the entrance to the first floor. Assessment of damage to this state-of-the-art medical center was still in progress at the time of this writing, but one VA official estimated that restoring full functionality would take 24 to 36 months. Like everything in the hospital, imaging and computer equipment was exposed to abnormally high temperatures, humidity, and mold.

The Department of Veterans Affairs has pioneered development and deployment of a nationwide electronic patient record (EPR) information system for its medical facilities. The primary component of the Veterans Integrated Service Technical Architecture (VistA) is its patient information database and software that supports specialty disciplines, such as a RIS for diagnostic imaging. A robust "recover all" program protects this system. EPRs for the 36,000 patients of the New Orleans VAMC were restored at the Houston VAMC two to three days after the hospital's evacuation.

AFTERMATH OF THE STORM

Hurricane Katrina created a "see-through" hospital from one end of Hancock Medical Center to the other because it was necessary to remove four feet of drywall from the base of the first floor throughout the hospital. Despite the severe damage, hospital personnel sanitized, dried out, and walled up the emergency department so that it could offer treatment to the community, Lindekens said. The emergency department reopened in early October, supplemented by portable medical "MASH" tents used as surgery rooms in the front yard.

GE Healthcare supplied the hospital with two portable x-ray units, and Agfa Healthcare provided a CR reader, laser imager, and stand-alone diagnostic workstation. The hospital is archiving images with its offsite service storage provider. A T1 line was connected to transmit Hancock's images to radiologists at Memorial Hospital in Gulfport for interpretation because it took hours for the radiologists to maneuver through the damaged road system from Gulfport to Bay St. Louis.

Radiology administrator Bill Monts de Oca went to the hospital on the day of the hurricane to assist his colleagues in moving patients to the second floor. Entering his battered department, he encountered two snakes swimming in one of the x-ray rooms.

At Touro Infirmary, only a few members of the 14-person radiology hurricane team were needed to ride out the storm at the hospital once the decision was made to limit services to conventional radiography. But everyone stayed, helping to move patients, clean, and relay patients' food trays up six flights of stairs. Radiology administrator Hitzman became a hospital van driver, transporting patients to Baton Rouge for admission to other hospitals.

"I'm so proud of what the radiology staff and my director did," Keene said. "They could have told me that because there were minimal radiology services to offer, they were leaving. Instead, they stayed and took care of our patients, showing tremendous compassion and courage."

A separate generator dedicated to the hospital's information system, including its RIS, kept the systems running. Modern Healthcare reported that Touro Infirmary CIO Peter Dougherty drove a hospital van containing all the hospital's computer servers and a set of backup tapes with patients' clinical information to Atlanta when the hospital was evacuated by the National Guard on Sept. 1. Touro Infirmary does not have a PACS. It reopened with limited functionality on Sept. 28.

At Memorial Hospital Gulfport, diagnostic imaging director West lived and worked in the hospital for 11 days straight. He and his radiology team sat out the storm unaware of the extent of the devastation taking place in the region. They had no communication with the outside world, with the exception of short-lived access to the Internet through a T1 line. It took days before some staff learned that their homes had been destroyed, along with those of 400 colleagues and 40 staff physicians.

The radiology hurricane team never faltered, West said. The emergency department's workload doubled during the first 10 days following the storm. The radiology department went into "downtime protocol," in part because the order entry system, RIS, and digital dictation system were somewhat dysfunctional and the emergency department's triage mode precluded routine PACS protocol.

"ER staff passed paper orders to us," West said. "If the RIS was up, we put the information into it. If it was not, we manually processed everything through the system as fast as we could."

Onsite radiologists, who also camped out in the hospital for the 11-day period, viewed images on a monitor using a freestanding Web product, dictated onto tape cassettes, and handwrote impressions on paper, which was walked back to the ER. When they weren't imaging, the radiology staff typed reports. Not a single x-ray film had to be printed. Information was entered into the RIS and images reconciled when they could be.

"The entire department, as well as everyone in the hospital, was amazing. People who had no idea if their families were alive or if they had homes stayed on the job and worked unbelievably hard for a very long duration," West said.

The "team A" that rode out Katrina at the Ochsner Clinic consisted of 28 people, including three radiologists and three residents. They lived at the hospital for six days, most working 12-hour shifts and some working around the clock. In addition to performing imaging procedures, they mopped wet floors, emptied buckets, covered equipment, kept the department clean, and assisted wherever they could.

Paper order requisitions were distributed throughout the nursing floors of the hospital, and all procedures were logged. When the RIS was reactivated, the orders were backloaded into the system, and once they were given accession numbers, they were matched with images on the PACS. The process went smoothly, Ortiz said.

The department had been in the process of implementing a new digital dictation system, and the software for it had been loaded onto the diagnostic workstations. The radiologists dictated reports using the new system and also wrote out interpretations that were hand-delivered to the emergency room physicians.

When Ochsner swapped out its tired first team for "team B," the replacements worked seven-day/12-hour shifts and slept at the hospital. They maintained this schedule throughout September.

The radiology department reactivated enough modalities to offer all its imaging services except MRI. Service engineers Brian Blanchard and Kevin Woodward restored the PACS and stayed to help ramp up other IT systems. A GE team began to restore its MR magnet and helped the department bring up other modalities.

Thanks to its huge diesel generators, VA Gulf Coast's Biloxi campus never lost power or air conditioning. All modalities, as well as the VistA RIS and VistA Rad PACS, were operational. The VA Gulf Coast did, however, lose its WAN connectivity with three outpatient clinics located in Mobile, AL, Pensacola, FL, and Panama City, FL.

Network connectivity was also lost with the University of South Alabama, where radiologists were contracted to read after-hours emergency studies performed at the Biloxi hospital, using teleradiology.

Woman's Hospital in Baton Rouge has Louisiana's largest neonatal ICU, and it served as the triage point for all intensive care babies in the area. The radiology department worked at about 150% throughout September, according to Dr. James Ruez. The pediatric workload was offset, however, by a loss of approximately 50% of mammography volume.

The radiology department had been scheduled to begin a phased replacement of analog mammography units with digital systems. The drastically reduced mammography volume made that process much easier. The vendor installation team slept in physician call rooms, and clinical applications specialists stayed at the homes of radiology staff, as no hotel or motel rooms were available in a 180-mile radius.

Fearing the worst from Hurricane Rita, the University of Texas Medical Branch at Galveston radiology department shut down all equipment in the main department, including nonessential RIS and PACS components. Only the PACS in the ER remained active. One CR, one DR, and one emergency department CT were connected to emergency generators. A four-person core team rode out the storm in the hospital.

Staff radiologist Dr. Roland Mestayier described the challenge for the radiology department at Singing River Hospital as "the only game in town for two weeks." Twelve members of the department were among those who camped out in the hospital. ER business was brisk, and the fact that the RIS and PACS worked flawlessly throughout the hurricane and in the busy weeks following it impressed the ER staff.

As this article went to press, Hurricane Wilma had just marched across Florida. Radiology departments in the state had prepared for yet another potential catastrophe.

Ms. Keen is a PACS consultant and imaging technology analyst with i.t. Communications, headquartered in Palm Beach, FL. Her industry consulting includes engagements with Agfa Healthcare, Eastman Kodak Company, GE Healthcare, Imaging Dynamics Company, IDX, Merge-eFilm, Philips Medical Systems, Siemens Medical Systems, SmartPACS, Sorna Corporation, and Talk Technology.

You can help prepare for disaster: Katrina, Rita, and beyond

Do you have disaster preparedness suggestions or strategies to share? Do you have observations about what happened during the Gulf Coast hurricanes that might provide insights on how radiology can be better prepared for the next disaster?

Please send your ideas and comments to the editor, John C. Hayes, via e-mail (jhayes@cmp.com). Please include disaster preparedness in the subject line. We'd like to present this information on our Web site, diagnosticimaging.com, and in the magazine.

We believe that by collecting and sharing this information, radiology departments everywhere will be better prepared when disaster does strike again.