Lessons Learned

North Shore-LIJ's evacuation of Staten Island University Hospitals North and South and Southside Hospital went smoothly, but there was room for improvement. The Incident Command team performed an after-action assessment, or "hot wash," to evaluate performance and identify what would be better for the next evacuation. Solazzo explains:

You learn from each event. We do a hot wash... a post-action understanding of how we continuously can improve. So from that perspective you look at it as a very large-scale drill. What did we do right? Where can we continue to improve our situation? So it’s never ending. I think we get better as time goes on, but the bar keeps on getting higher.

The major takeaway from Irene was that the Incident Command staff had focused almost exclusively on the evacuating hospitals and hadn't paid enough attention to the receiving hospitals. "We really needed to split up our staff in the Emergency Operations Center at the leadership level to concentrate just as much on the hospitals receiving evacuated patients as the hospitals that we were evacuating," says Romagnoli. "As difficult as it was to evacuate those people, it was putting tremendous strain on our other facilities. "The solution was to move staff, medications and resources along with evacuated patients. Romagnoli amplifies:

If you’re sending me 10 patients, you should be sending me four or five nurses, too. When there’s patients going, staff has to go with them. If they need a three-day supply of meds, send it with the patient or you’re going to clean their pharmacy out overnight. Those support mechanisms such as medications, staffing, they should come with the patient.

The hot wash identified three other changes that would improve performance during evacuations and other emergencies:

  • Increase backup, reduce shift lengths and stagger shifts for Incident Command staff at the Emergency Operations Center (to reduce fatigue and improve decision-making)
  • Increase communications updates to employees (to reduce the volume of inbound calls from employees)
  • Tap licensed and certified healthcare professionals from among the corporate staff (to reduce the need for outside staffing) [22]

The hot wash also found that two planned upgrades to the hospitals' patient tracking systems—Electronic Health Records and bar-coded wristbands—would have reduced the workloads of staff performing the evacuation had they been in place. Finally, the assessment called for renovations and new construction at the hospitals to take flooding into account and move power systems and critical service areas above ground level. [23]


Southside Hospital
Image courtesy of North-Shore LIJ

Government. Hospital officials were keenly aware of the ripple effect that occurred during emergencies, and placed a high value on cooperation among competing hospital systems. This cooperation, however, was informal and ad hoc, usually in the form of telephone calls to ask for assistance and share knowledge of available beds and other resources.

In the aftermath of Irene, North Shore-LIJ and officials at other hospital systems identified a role for government in coordinating and formalizing the interactions between government and private hospital systems and among the systems. There were two barriers to achieving this: hospitals tended to fall outside the scope of municipal emergency management agencies, and most hospital systems spanned multiple jurisdictions. For instance, North Shore-LIJ had one facility, Long Island Jewish Medical Center, which straddled the New York City-Nassau County border.

The lack of government coordination with private hospital systems became especially evident when the New York City Emergency Medical Services continued to send emergency patients to hospitals that were evacuating. In general, New York City officials knew how many police officers were on duty and how many fire trucks in service, but they did not know how many hospitals had crowded emergency rooms. The city's Office of Emergency Management needed an official responsible for tracking healthcare resources, says Romagnoli. “Health care could be better coordinated at the municipal level. There’s an expectation that hospitals can take care of themselves. Not true.”

Federal funding was another issue. Very little of the federal funding to improve emergency services that flowed into the city after the 9/11 terrorist attack went to hospitals, observes Romagnoli. The focus on emergency services was on first responders: firefighters, police officers and emergency medical technicians. First responders delivered people to safety and to help. "We were that safety and help," notes Romagnoli. "We’re the first receivers. The emergency eventually ends up at our doorstep."

On November 28, 2011, New York State Department of Health Commissioner Nirav Shah met with Dowling, Solazzo, Romagnoli, Mahoney and North Shore-LIJ Corporate Director of Security Scott Strauss to discuss North Shore-LIJ's response to Hurricane Irene and its role as Regional Resource Center for healthcare in Nassau County. The North Shore-LIJ executives presented their improved evacuation plan, which included a Patient Evacuation Transfer Form, an Asset List, and hurricane maps.

The Patient Evacuation Transfer Form provided hospitals and nursing homes throughout Long Island with a standard way to produce a set of abbreviated medical records to accompany evacuated patients. The Asset List was a centralized inventory of beds, equipment and resources at healthcare facilities throughout Long Island. The hurricane maps were versions of SLOSH Model maps, which show the areas vulnerable to hurricane surges, that the team modified to include information about healthcare facilities.

The team had developed in the evacuation plan to better meet North Shore-LIJ's needs for hurricane evacuations and to better serve its role as Nassau County Regional Resource Center. The North Shore-LIJ executives recommended that the commissioner present their evacuation plan as an option for other healthcare systems throughout the state, says Romagnoli. [24]

Conflicted. When Irene's impact proved less than anticipated and the storm surge did not disable the three hospitals, second-guessing began. Moving patients was risky. To justify a move, the threat to patient safety from a storm or other disaster had to be greater than the threat to patient safety from the evacuation. In hindsight, North Shore-LIJ's patients would have been safer remaining in the facilities. But happily, North Shore-LIJ carried out the evacuation without adverse consequences. The company's quality control staff reviewed the evacuation and validated the Incident Command team's observations. "We had absolutely no patient come to harm whatsoever," says Solazzo.

This gave Solazzo and Romagnoli contrary impulses when considering future storms: the effectiveness of the evacuation reduced the risk associated with moving patients and the minimal impact of the storm reduced the risk of keeping patients in the facilities. "So you have these two balancing factors in your mind now, one pushing you to evacuate more quickly and one pushing you to say there’s just no need," says Solazzo. He and Romagnoli were confident in North Shore-LIJ's ability to evacuate patients, and convinced in retrospect that a storm of Irene's magnitude did not meet the threshold for triggering an evacuation.


[22] “A Hospital System's Response To A Hurricane Offers Lessons, Including The Need For Mandatory Interfacility Drills,” Health Affairs , 31, no.8 (2012):1814-1821

[23] Ibid.

[24] Author's telephone interview with James Romagnoli on April 15, 2013.