FORT LAUDERDALE, Fla. — On Monday, five days after Hurricane Ian hit the west coast of Florida, critically ill patients on ventilators arrived by helicopter at Cleveland Clinic Florida in Weston.
Unlike normal transfers, the handoff from one medical team to another consisted only of a word-of-mouth report on the patient’s medical condition. A lack of power, water and staff had made their relocation from Lee Health hospitals imperative.
“I had to remind our staff that this isn’t normal,” said Scott Ross, chief medical officer at Cleveland Clinic Florida. “I told them, don’t get frustrated by how quickly patients are arriving or the lack of information we are receiving. They are coming from hospitals where there is no electricity, no access to medical records. They haven’t even printed paper charts because it is just not feasible.”
While Florida hospitals pride themselves on hurricane preparation, most recovery plans did not consider the catastrophic damage from a major storm to the utilities — such as water systems — that support them. In the wake of one of the most powerful hurricanes to hit Florida, the scramble to transfer patients from southwest Florida hospitals shows the massive effort required to respond to a medical emergency on a grand scale, even in the age of technology.
In a Facebook video a day after Ian hit the coast, Lee Health President and CEO Larry Antonucci explained the desperate situation his health system faced: “At the present time, our structures and our facilities are in good shape. They weathered the storm well. But our infrastructure is challenged in the way of water supply and power.”
Antonucci said the health system used its generators. But some of its hospitals, including Golisano Children’s Hospital, did not have running water. “We cannot run a health system without running water,” he said. “It’s critical to what we do.”
How plans were made
As emergency responders arrived on the battered west coast, hospital leaders across the state participated in disaster recovery calls, learning at one point that as many as 900 to 1,000 patients would need to be relocated. Hospitals in the hardest hit area of southwest Florida were dealing with disruption in the power and public water systems, and one hospital had significant damage. All hospitals were asked to report their open beds, and then asked again because of staff shortages to report how many of those open beds were staffed with health care workers.
Across the state, hospitals began receiving patients — some with little or no notice.
Ross at Cleveland Clinic said he had some advance notice that his hospital would get ICU patients, but those arriving for the regular nursing floors caught him off-guard.
“Five or six patients arrived today and we were not expecting any of them,” Ross said Monday. “Once they showed up, we rapidly triaged and assessed them. We learned their medical history almost piecemeal from the family at the bedside and the transport system.”
The evacuation unfolds
Shuffling the patients to other hospitals became a grand-scale effort, with volunteer emergency medical services workers from states like Mississippi and Tennessee pitching in. All the while, Lee Health CEO Antonucci desperately tried to get power and water back, a feat eventually accomplished only after about 400 patients were transferred.
“Evacuation is not necessarily the first action to be contemplated,” said Mary Mayhew, president and CEO of the Florida Hospital Association. “You want hospital services before, during, and after a storm. It’s extremely disruptive to patients and you have to take that disruption into consideration as well.”
Mayhew said the logistics behind “the monumental task” of transferring hundreds of patients took coordinated effort with her organization, the hospitals and the state.
Some patients required more than one transfer.
When a trauma patient from the west coast showed up at Cleveland Clinic, Ross said he immediately called Broward Health, the closest hospital with a trauma center. “The luxury we have is cellphones, faxes and medical records. Lee County is running blind.”
The babies need help
Even before the adults arrived in South Florida, vulnerable premature and sick babies became a top priority.
At Golisano Children’s Hospital in Fort Myers, parents of the tiniest babies rode out the storm hours with their little ones in the neonatal intensive care unit. They watched as the first floor flooded and the hospital lost power and water. When the storm passed, the decision was made — 67 babies needed to be relocated.
South Florida’s two children’s hospitals, Joe DiMaggio and Nicklaus, responded, relaying the number of beds available as did other children’s hospitals in Florida.
That began a 48-hour effort of helicopters and ambulances flying and driving back and forth across the state of Florida, dodging debris to transport patients and their families.
Communication had become nearly impossible with cell towers down and power out in most counties on the west coast, and some babies arrived while medical workers were still trying to locate their parents.
Nicklaus Children’s Hospital’s two helicopters and six ambulances, known as the “life flight team,” were deployed to transfer NICU babies from Golisano to hospitals in Miami-Dade and Broward counties. The transport units are like mini-traveling ICUs.
“Watching this unfold, I wanted to jump in right away to help in whatever way possible,” said Dr. Marcos Mestre, vice president and chief medical officer of Nicklaus Children’s Hospital. “The first thing though is safety. The air space had to be clear, the landings had to be clear, and so did the roads for our ambulances. That took some patience.”
Nicklaus took in five babies from Golisano and a handful of children who needed cancer care. “Our biggest limitation was staffing,” Mestre said. “It’s no secret staffing is an issue throughout the country, and we are no exception.”
But after learning the circumstances, nurses agreed to come in to help, and families were allowed to sleep in the rooms with the babies. The babies are still at the hospital. “At one point they may be able to go back to Golisano, but for now that hospital is not ready to have patients returned,” Mestre said.
Dr. Ronald Ford, chief medical officer of Joe DiMaggio Children’s Hospital in Hollywood, reported his hospital and sister hospitals in Pembroke Pines and Miramar took in 22 babies. Those in need of a higher level care arrived first.
“It’s been a constant stream of communication between our team and their team to identify which babies came first, how they would be transported, and what type of care they need,” Ford said as the babies were arriving on Sept. 30.
HCA faces a double whammy
HCA Florida Healthcare has its own emergency command center where it prepares for hurricanes and coordinates resources and patient transfers. Preparation at that center started days in advance of Ian and kicked into overdrive following the storm’s landfall on Sept. 28.
Two of HCA’s hospitals fell directly in the path of the storm’s eyewall. In Englewood, the 100-bed HCA Florida hospital had its power knocked out almost immediately and a generator kicked in. But because the city’s water supply was damaged, patients need to be transferred to nearby HCA locations. The hospital has since reopened. However, in Port Charlotte, HCA Florida Fawcett Hospital took a direct hit; the storm damaged the roof and forced 160 patients to be evacuated. That hospital remains closed, although repairs are underway.
“When the storm passed, we felt we had to move all the patients out to safer locations and give teams a chance to remediate the facility,” said Dr. Ravi Chari, president of HCA Healthcare West Florida division. “It required tremendous coordination.”
Chari said his company’s command center worked closely with the state to line up the ambulances that would take patients out of the damaged hospitals. Each patient’s medical needs were matched with the best hospital within the 49 under the HCA Florida Healthcare umbrella that had the right care, he said. Staff in the affected hospitals were given free food, water, fuel and home materials like tarps.
While HCA Florida Healthcare leaders navigated the damages to its west coast locations, the company’s east coast hospitals received patients from the Lee Health system.
“After a disaster, everyone tries to help everyone,” Chari said. “Other hospitals knew we were hit directly, and the CEOs texted me to say we are here to help and we did the same with Lee Health.”
All the elements of chaos
Over the last week, as medical vans transported patients all over the state, the biggest challenges hospital leaders encountered have been people-related. The receiving hospitals needed to staff the beds that west coast patients would fill, track down patients’ family members to notify them of the new location and find nearby hotel rooms for patients’ families. In Broward County, 19 hotels partnered with VISIT FLORIDA to house some of the families at no cost.
While Lee Health hospitals are fully or partially operational again, some patient transfers from the west coast continue.
“Some of the hospitals are unable to respond to new demand for services because of staffing issues,” said Mayhew, of the Florida Hospital Association. “So many staff were displaced and impacted by the hurricane. That is why patients may still be transferred to other hospitals outside of the region.”
Now what?
Hospitals that took in patients now face a quandary with discharges. Many of the hospitalized patients being treated around the state don’t have homes to return to.
“Hospitals can only discharge patients if there is a safe, appropriate place to discharge to,” Mayhew said. “Elderly patients who normally would go back to a nursing home or assisted living facility may not have that option with damage caused by the storm. There are a lot that are not fully operational in southwest Florida.”
Mayhew said when patients are delayed in their discharge, it has a ripple effect, which could be a problem for west coast hospitals. “It further compounds their capacity to respond to other demands for inpatient care,” she said.
What happens the next time?
Across South Florida, hospital leaders look at the west coast’s experience as a warning.
“There will be a lot of reflection,” Mayhew said. “You always want to be focused on where there are further opportunities for improvement.”
She points out that hospitals have been upgrading their facilities in Florida for years to prepare for hurricanes. The majority withstood the harsh winds of Ian, she notes. The area that needs increased focus is the flooding and surge risk, she said.
Jaime Caldwell, of the South Florida Hospital Association, said the conversation around planning for hurricanes throughout the state among hospital leaders definitely will change. “There will be a lot more discussion about hurricanes that have water impacts, as Ian did.”
Mestre at Nicklaus said Florida hospitals have generators but power wasn’t the impediment on the west coast. “A water pipe being ruined ... those are things that are not part of a regular emergency plan. You learn from that.”
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