Safety and Accident Prevention

he crisis that was Hurricane Kat- rina caused several ethical and managerial dilemmas, which will

provide further guidance as we begin to plan for the avian flu pandemic that the experts tell us is (to use a theater metaphor with a double entendre) wait- ing in the wings. The huge natural disas- ter resulting from Katrina and its after- math engulfed nursing homes and hospitals, which faced the daunting prospect of caring for severely ill patients as a cascade of events interfered with their ability to provide even the most rudimentary care. Caregivers faced a widening catastrophe that included failed public electrical and water service, failure of emergency electrical genera- tors, and, with rising flood waters, the critical need to move patients who were too ill to transport. This resulted in nursing home residents abandoned to rising flood waters, allegations of eutha- nizing of hospital patients who could not be moved, and troubling questions of whether those who should have known better failed to plan for the extremes that were Katrina and its after-

math. With staff scattered, facilities and equipment damaged or ruined, and demand building as residents return, efforts to deliver health services in New Orleans now face a catastrophe in slow motion.

The Charity Hospital complex, which includes Charity Hospital and its sister, University Hospital, has been judged too badly damaged from Katrina and the flood that followed to be salvageable. It is estimated that rebuilding of Big Char- ity, which is part of the Louisiana State University system, will cost $250 mil- lion, compared with $350 million for a replacement facility (Chan and Harris 2005; Connolly 2005). In the mean- time, Charity Hospital remains closed; rebuilding it is problematic (Barringer 2006). Beyond the physical damage to a dozen New Orleans-area hospitals are the staff and manpower problems that result from the displacement of thou- sands of medical personnel (Connolly). Most have yet to return; it is likely that many never will.

The purpose of this Nexus is not to address rebuilding New Orleans’s health services delivery system, however. The ethical and managerial issues that arose when hospital and nursing facility staff were overwhelmed by the hurricane and flood must be identified, for they will provide an early warning to health ser- vices organizations (HSOs) who might face similar problems, as well as an ana-

logue to the avian influenza pandemic that looms just over the horizon.

Almost all HSOs in New Orleans were damaged by Katrina, but, with some exceptions, not so badly that they could not continue functioning. It was the flooding that occurred shortly after the storm ended that caused horrific events to unfold. What happened at Memorial Hospital and St. Rita’s Nurs- ing Home is paradigmatic of the kind of situation that gives health services execu- tives and clinicians nightmares. Both providers had dozens of patients, many too ill to evacuate, even if transport had been available in a timely manner.

Examples

The Louisiana attorney general and the Orleans Parish district attorney have launched investigations—including empaneling grand juries—into allega- tions of approximately 215 deaths at five hospitals and 10 nursing facilities in metropolitan New Orleans. The probes are investigating whether critically ill hospital patients were given lethal doses of painkillers to end their suffering after they were trapped by power failures and rising floodwater. Being investigated at nursing facilities are resident abandon- ment, improper evacuation, and negli- gent homicide. Owners have denied any inappropriate actions (Johnson 2006). The actions of staff and administrators are the focus of attention. Negligence is

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E t h i c s , L a w , a n d M a n a g e m e n t

KURT DARR

NEXUS

30

Kurt Darr is a professor of hospital adminis- tration in the Department of Health Services Management and Policy, The George Washington University, Washington, DC, and an executive editor for Hospital Topics. ©2006 by Kurt Darr.

Katrina: Lessons from the Aftermath

a concern; more important, however, are the allegations of euthanasia.

Nursing Facilities

Salvador and Mabel Mangano, who own St. Rita’s Nursing Home, have been charged with multiple counts of negli- gent homicide in the deaths of 34 resi- dents who died in the flooding after lev- ees were breached following Katrina. The couple is charged with failing to act after receiving warnings that residents should be moved as Katrina approached. The attorney general has charged that St. Rita’s residents could have been evacuat- ed. Warnings came from St. Bernard Parish county emergency preparedness officials and the media, and local officials had ordered a mandatory evacuation as Katrina approached. As a Medicaid- qualified facility, St. Rita’s had an evacua- tion plan, which it failed to implement. St. Rita’s managers also declined city offi- cials’ offers of two buses to use in evacua- tion. In addition, St. Rita’s never imple- mented the contract with a local ambulance company to provide vehicles in the event of an evacuation. The attor- ney for St. Rita’s has stated that the own- ers were unaware of the mandatory evac- uation that had been ordered and that evacuation of the severely ill residents who needed feeding tubes, oxygen, and medication would have caused their deaths (Dewan and Baker 2005). The concern that nursing home residents would be at greater risk while being evac- uated is not to be ignored. Nursing home residents are likely to be frail and require significant, continuous support and clinical intervention to stay alive. For example, at least 35 persons from HSOs died when Houston was evacuat- ed in the face of the threat of Hurricane Rita, which followed Hurricane Katrina by only a few weeks (Appleby 2005). The need to decide whether to evacuate, with or without official sanction, puts an almost untenable burden on managers.

Hospitals

Memorial Medical Center was sur- rounded by 10 feet of floodwater when emergency generators failed. Lack of electricity caused ventilators, dialysis machines, heart-rate monitors, and air-

conditioning to stop. This left 160 seri- ously ill, bedridden patients stranded in the dark and in an increasingly inhos- pitable environment (NewsMax 2005). Exhausted nurses and doctors squeezed hand-held ventilators. Over the several days before evacuation finally occurred, daily food rations were reduced from three to two to one (Chan and Harris 2005). A failed water system meant no fresh water for drinking or even to meet basic sanitary needs such as rinsing bed- pans or flushing toilets. The lack of air conditioning caused high interior tem- peratures that further debilitated patients and increased the exhaustion and general discomfort of staff. The problems at Memorial were compounded by the 1,800 local residents who were sheltering there from the storm and had to be given food and water from the limited supplies available before they could be evacuated (Chan and Harris). In antici- pation of the planned evacuation—that flooding prevented—the hospital’s phar- macy had been locked to protect its con- tents from looters. Inexplicably, when evacuation proved impossible, no one who remained had access to the pharma- cy. This contributed greatly to the med- ication shortages that occurred, and care- givers may have had to allocate drugs to those with the best chance of surviving (Crary 2005).

The impossibility of moving patients in a situation of virtual hopelessness caused Memorial staff to consider extreme solutions such as euthanizing patients to minimize their suffering. It was reported that one physician was seen holding syringes and that some physi- cians expressed a willingness to adminis- ter the death-causing medication as a “mercy killing.” It was also reported that there was talk of euthanizing some criti- cally ill patients as the storm approached. There was no report that staff actually administered lethal injec- tions, however (NewsMax 2005).

Ethical and Managerial Issues

Beyond the basic question of whether to evacuate, which is almost entirely a utilitarian (the greatest good for the greatest number) ethical judgment, an important ethical issue arose because of

widely varying perceptions of how patients and residents should be priori- tized for purposes of rescue.

A telling example of this failure of understanding occurred at Lindy Boggs Hospital in the days after Katrina. Physicians and staff performed Her- culean feats of virtually nonstop care under the most daunting and primitive conditions, but they had to conclude that it had become necessary to evacuate the hospital. They determined that the most critically ill patients should be evacuated first and they prioritized and identified patients using that criterion. To clinicians applying medical criteria, it was logical that the less ill could remain in the hospital longer with less risk of untoward effects.

The call for assistance from Lindy Boggs Hospital was answered by fire- fighters from Shreveport, Louisiana, who came to assist in New Orleans’ res- cue efforts. They applied a very different set of criteria for determining the order of evacuation—criteria based loosely on the system of military triage. The fire- fighters insisted on evacuating the least ill first and left the most ill for later transport; because they controlled the means of evacuation, their view pre- vailed. Given these circumstances, it was inevitable that some of the sickest patients would expire. The investigations underway may determine the effect of the decision to leave the most critically ill behind.

As further evidence of the discordance between the criteria of rescuers and clin- ical staff, some helicopter pilots who landed at Memorial Hospital to rescue patients reportedly only wanted to trans- port pregnant women or babies (Chan and Harris 2005). Apparently, those helicopter pilots were applying yet another ethical criterion—one based on saving the young and those who would bear young as the most desirable to save, regardless of acuity of illness.

Lessons Learned

It is easy to fault HSO managers for not acting more aggressively to evacuate patients. Even in the face of a mandato- ry evacuation order, however, managers have ethical and legal responsibility for

HOSPITAL TOPICS: Research and Perspectives on Healthcare 31

the well-being of their patients, and it is not unreasonable for them to exercise great caution in ordering an evacuation. The New Orleans levees were expected to hold, but once flooding started it was too late to move the most critically ill. From an ethical perspective, managers who decide to disobey the law because of a higher ethical duty (beneficence towards patients) are engaging in civil disobedience. In disobeying the law, they must recognize that they risk sanc- tion by authorities for their actions.

The Katrina example makes it clear that public officials without health ser- vices experience have little understanding of how sick hospital patients and nursing facility residents can be and typically are. The level of acuity in both types of HSOs is almost certain to increase.

Another example of clinical and ethi- cal issues that are raised by a need to evacuate is instructive. Following a train derailment, leaking tank cars released clouds of poisonous chemicals near an acute-care hospital. The local fire chief asked the administrator how quickly patients could be evacuated. An inten- sive care unit full of ventilator-depen- dent patients made the decision relative- ly easy—evacuating would be riskier than remaining in place. As a precau- tion, the hospital’s ventilation system was shut down. Luckily, the cloud of poisonous gas moved away from the hospital (Appleby 2005). Arguably, even if the wind had been unfavorable, the administrator made the correct decision because the possible death of patients was preferable to almost certain death.

HSOs that care for those who might have to be evacuated must develop means to orient local emergency pre- paredness officials to the special needs of patients and residents. Only by under- standing the clinical needs and circum- stances of HSOs’ clienteles will officials have informed and realistic expectations. A tour of the facility with explanations of the clinical support needed will great- ly diminish this general level of igno- rance. Such orientation and training should precede efforts to develop com- munity-wide protocols that will be applied when situations such as those in New Orleans occur.

HSOs must work with community emergency preparedness officials and emergency response units such as police, fire, and emergency medical technicians to develop protocols that establish prior- ities for evacuation of those residing in them. The clash likely to occur between use of clinical and military triage criteria must be identified and resolved. As noted in the previous Nexus (Darr 2006), which discussed the impending avian flu pandemic, when capacity (for evacuation or treatment) limits are reached and not all can be rescued or saved, some predetermined, organized method for decision making must be present. Rules of thumb and situational ethics are not likely to produce societally desirable results.

Just-in-time inventory systems, which are increasingly common in HSOs, depend on reliable replenishment on an almost daily basis. Media reports did not specifically mention the use of just-in- time inventory systems in New Orleans- area HSOs, but the fact that medica- tions, supplies, and food were exhausted after only a few days strongly suggests that most HSOs had very limited inven- tory on-site. The negative aspects of just-in-time inventory were discussed in the previous Nexus (Darr 2006). Use of just-in-time inventory systems for cer- tain types of medications and supplies should be reexamined in light of the Katrina experience.

In the wake of the experiences of Hurricanes Katrina and Rita, HSOs are likely to rework their disaster prepared- ness and evacuation planning. Commu- nication was especially problematic, and HSOs have turned to satellite phones and more high-tech devices (Appleby 2005). Problems regarding communica- tions between HSOs and civil authori- ties should be easy to resolve, but they are present in virtually every emergency situation. Given the availability and low cost of wireless communications, includ- ing radio and shortwave, the reasons for these difficulties seem almost unfath- omable. Simple disaster planning cannot help but include adequate communica- tions capability, and failure to have it in this day and age strongly suggests man- agerial incompetence.

The availability of emergency electri- cal power (for more than a few hours) and water supplies is critical to provid- ing clinical services. Yet, as Katrina and other disaster situations have shown, emergency electrical generators continue to fail with alarming frequency because of mechanical problems or because they are situated in basements or other loca- tions that make them vulnerable to flooding. Even more unforgivable are the reports that fuel supplies were exhausted within 24 to 48 hours or less. Maintaining an adequate supply of water poses greater difficulties. Else- where, hospitals have resorted to bring- ing in water tankers. This may be infea- sible in the face of severe flooding, but it should be considered when warnings have been issued. On-site storage in a water tower or tank is an option to con- sider, especially in areas prone to natural disasters such as hurricanes or floods.

Conclusion

HSOs should expect that Murphy’s Law will apply to all emergency situa- tions. This prospect should not diminish contingency planning, however. Given the lessons of Katrina, it is likely that HSOs will be more aggressive in dis- charging those who are safe to discharge, limiting elective admissions, and ensur- ing that adequate supplies of all types are available on-site for more than a few days when a major storm is predicted.

Of all the failures that occurred in New Orleans, communication is the one most easy and least costly to remedy. The reports that some HSOs were buy- ing boats and chartering helicopters to be used in the event of an emergency evacuation seem to be more a matter of an emotional reaction than good plan- ning. Beyond helicopters’ vulnerability to weather and the likelihood that hav- ing a contract will not guarantee avail- ability, no HSO should develop a false sense of security. It is likely in all such situations that independence and look- ing to one’s own assets and staff are the best ways to weather the storm.

REFERENCES Appleby, J. 2005. Hospitals rework their dis-

aster plans. USA Today, October 21, 3B.

32 Vol. 84, no. 2 Spring 2006

Hospital Topics 84 (1): 32–35. Dewan, S., and A. Baker. 2005. Owners of

nursing home charged in deaths of 34. The New York Times, September 14, A1.

Johnson, K. 2006. Grand jury to probe hos- pitals. USA Today, January 16, 01A.

NewsMax. 2005. Katrina aftermath: Probe of 215 hospital deaths launched. 7 (12): 40–41.

HOSPITAL TOPICS: Research and Perspectives on Healthcare 33

Barringer, F. 2006. Long after the storm, short- ages overwhelm New Orleans’s few hospi- tals. The New York Times, January 23, A12.

Chan, S., and G. Harris. 2005. Hurricane and floods overwhelmed hospitals. The New York Times, September 14, A21.

Connolly, C. 2005. New Orleans health care another Katrina casualty. The Washington

Post, November 25, A3. Crary, D. 2005. Hospitals fight for life as flood-

waters recede. The Washington Times. http:// www.washingtontimes.com/functions/print .php?StoryID=20050919-23346-6588r (accessed September 20, 2005).

Darr, K. 2006. Beyond triage: Avian flu and the impending services demand crisis.