Dialysis Chains Prepare for DisasterDelicia Honen Yard
January 12 2009
Plans are in place to enable dialysis facilities to function during power outages and disruptions in water supply
FOR MOST patients with end-stage renal disease (ESRD), local dialysis centers are a necessary component of their lives, providing crucial—even lifesaving--treatment. But are dialysis facilities prepared for emergencies, such as power outages and disruptions in water supply, that could hamper their ability to dialyze patients? Such emergencies in recent years have prompted major dialysis chains to rethink and restructure their disaster-preparedness plans.
The massive blackout that struck the Northeast and other areas in August 2003 prompted Fresenius Medical Care to cast a wider emergency-preparedness net for its 1,650 outpatient dialysis clinics. “More than 100 of our facilities were affected by that power outage,” recalled Bill Numbers, vice president of operations support and incident commander for disaster response and planning for Fresenius. “We always had disaster planning at the local levels, but [after that experience,] we decided to do it at a more comprehensive, centralized level.”
With the lessons of the blackout fresh in their minds, Fresenius' first disaster-planning team was born. Numbers and his colleagues crafted procedures for handling future widespread power outages as well as a range of other emergencies—those that come with warning and those that do not. “We developed a plan for nuclear-plant failure, earthquake, ice storms and snowstorms, floods, and hurricanes,” Numbers said.
The catastrophic 2005 hurricane season featuring Katrina, Rita, and Wilma put a large segment of the kidney-care field to the preparedness test—and it failed, according to Jeffrey B. Kopp, MD, and the other members of the Kidney Community Emergency Response Coalition (KCERC). The coalition was formed in January 2006 by representatives of more than 50 government agencies and private organizations to address nephrology-related emergency planning and response needs.
“Hurricane Katrina and its aftermath was a message to the community of kidney patients and their providers that every patient, care provider, and dialysis facility needs to have a plan in place for disasters—and needs to practice these plans and revise them as knowledge of best practices improves,” said Dr. Kopp, staff clinician, Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). He also is a commissioned officer with the U.S. Public Health Service.
In a report published in the Clinical Journal of the American Society of Nephrology [CJASN] (2007;2:825-838), Dr. Kopp and his KCERC collaborators outlined key recommendations for nephrology providers, patients, and emergency personnel at the federal, state, and local levels. For example, providers are urged to make an emergency plan, which in part entails procuring and maintaining emergency equipment and supplies, planning the evacuation of patients and staff, and creating a list of emergency telephone numbers that will allow them to communicate with each other. Many of the recommendations for dialysis facilities are echoed in the requirements set forth in the federal final rule on emergency preparedness for dialysis facilities. Providers should also help patients keep updated lists of medication and dialysis-treatment information and prepare them for an emergency.
Yet Dr. Kopp remains concerned that relevant medical information for patients is not efficiently and rapidly made available to the special-needs shelters and dialysis facilities that must care for these individuals.
“We saw after Hurricane Ike [which made landfall in Galveston and Houston, Texas, in September 2008] that dialysis facilities in surrounding areas were able to promptly absorb evacuees who needed dialysis treatment,” Dr. Kopp said. “Nevertheless, evacuees frequently arrived at special-needs shelters without a health information packet, which provides information about their dialysis prescription, medication, estimated dry weight, and medical problems, including viral infection status. Without such information, it was difficult to provide these patients with optimum care.”
Critical needs
Fresenius' Numbers and his disaster-planning team identified three necessary elements that were missing during the 2003 blackout: the ability to bring in additional generator power to the affected dialysis facilities, a well-established communication process for Fresenius staff, and a plan for communicating with patients.
The first problem was solved easily. With Fresenius building 50-100 dialysis facilities a year, the company always has generators ready for new construction. “So now we've coordinated with the generator company to build some of those generators ahead of time and station them in their depots in advance of our construction needs,” Numbers explained. “That way, we have available at any moment 5-20 generators that we can call on in event of an earthquake, flood, hurricane…whatever.”
Next on the agenda was setting up a company-wide disaster-response team to carry out the procedures developed by the disaster-planning team. Members were recruited from every department of Fresenius. The team would be activated to help handle events that affected three or more Fresenius dialysis clinics; anything less was largely a local issue.
In an emergency situation, the first step—and what Numbers called a key to the disaster-response team's success—is having team members find a way to phone in for the conference call that takes place each day at noon Eastern time during a crisis. They have learned that even when landlines are down and cell phone networks are too full, text messaging via cell phone or BlackBerry usually remains operational, as do satellite phones and the two-way walkie-talkie capabilities of Nextel cell phones. Police stations and firehouses often will share their working phone lines with Fresenius employees needing to get on the daily conference call.
“We've been very successful with every single disaster, even Katrina, in that the locally affected managers were on those calls at 12 noon telling us what they needed,” Numbers said.
Dr. Kopp credited such regular conference calls with hastening the identification and resolution of patient and facility needs during one recent disaster. “The KCERC instituted a daily conference call during Hurricane Ike to coordinate responses,” he recounted. “A wide variety of people participated in the calls, including personnel from the Centers for Medicare & Medicaid services and its 18 nationwide ESRD Network organizations; nephrologists; nephrology nurses; dialysis unit directors; representatives from large dialysis organizations; vendors of dialysis-related equipment and supplies; and representatives from transportation companies.”
During these calls, the ESRD Network for the storm-ravaged region informed dialysis providers about how many people had called seeking a dialysis unit that could treat them. Nearby dialysis units described their capacity to accept additional patients. Affected dialysis facilities stated their needs, and call participants offered their expertise and assistance.
“The call was instrumental in ensuring that dialysis facilities could cope with the influx of new patients and could reopen quickly if they were shut down,” Dr. Kopp said. In addition, “The regularity of the conference call served as a dependable line of communication that was enormously reassuring to the affected facilities.”
Dr. Kopp noted that the calls helped various ESRD Networks develop relationships that made it easier to help one another in emergency situations. He hinted that even more help might be available in the future. “The National Disaster Medical System is considering plans to form nephrology response teams that would be available to supplement dialysis facilities in need of additional staff and possibly to provide dialysis treatments in federal medical stations.”
Address employees' needs
The daily conference calls help establish not only the needs of a given dialysis clinic but the more personal needs of the clinic staff. As a resident of Orlando, Fla., Dave McKenzie, a divisional vice president for dialysis provider DaVita and a member of DaVita's emergency-management team, has seen firsthand how important it is to assist employees who reside in a disaster area. “After living through the four major hurricanes that hit Florida [during a six-week period] in 2004, I learned how crippled the people on the ground can be because they're so focused on their families, their homes without a roof, no food, no water, no fuel, no school for the kids….There's got to be support coming in to help the teammates at ground zero so they can then help the patients.”
DaVita operates more than 1,400 outpatient dialysis clinics nationwide, and hurricanes have been the most common trigger of the company's emergency response. “Even with floods, mudslides, or fires, the affected area is typically smaller than with hurricanes, where 50 clinics can be out for a long time over a fairly large geographic area,” McKenzie said.
In fact, 2005's Hurricane Katrina was the impetus for the present-day emergency plans created by DaVita. “I think it absolutely was the magnitude of that event and what we learned from it as far as the need to be more prepared,” McKenzie said. “But we're continually updating as we experience events, whether they be hurricanes or floods or the fires in California.”
Emergency plans at another dialysis provider, Dialysis Corporation of America (DCA), are more focused on snowstorms than hurricanes because most of its clinics are located in the Northeast. DCA employees, however, are well prepared for whatever comes their way, says Joanne Zimmerman, RN, a certified nephrology nurse and vice president of clinical services at DCA. “Each facility has DCA disaster procedures that are followed and practiced quarterly,” Zimmerman noted. “The facility administrator and medical director manage each facility individually so emergency plans are tailored to meet that center's unique needs. The medical director of the facility serves as the director for any emergencies.”
Water treatment a priority
Like Fresenius, DaVita calls on its vendors to start staging supplies ahead of time whenever possible, and it has set predetermined call-in numbers and times so that the company's national emergency-response team members can communicate with one another as well as the managers of the affected facilities. Emergency-related responsibilities are classified into approximately 100 different accountabilities. “Our plan breaks down the needs that any one of our clinics or business offices could have,” McKenzie said. “For example, one of the responsibilities of the biomed team members is water. So they determine if the water is usable for dialysis treatment, and if it isn't, they're responsible for finding water and bringing it in on trucks or however they might get it there.”
Fresenius' Numbers calls these experts the company's “storm chasers.” “We've learned over the years that we've got to have water-treatment people who get into those facilities immediately to eliminate problems. If you have saltwater in a dialysis system, it can take 12-24 hours to clean it out, so we've got to get there first and fast. The storm chasers are the first guys we send in; they have everything they need to start up the water-treatment system in a dialysis facility. And that has really been a key to why we can open our facilities faster than anybody else.”
Tracking relocated patients
At DaVita, accountability for tracking down displaced patients falls to the information technology (IT) team. “Patients can end up in our clinics or in a competitor's clinics or in the hospital,” McKenzie said. “In some cases, we're able to stay in touch with a patient via telephone. But if a person were to evacuate from Louisiana, go to a relative's house in Ohio, and attend another DaVita clinic there, our system would pick that up through the person's ID information.”
DaVita also issues patients wristbands displaying the company's toll-free number. “We instruct them to call that number and let us know, for example, that they're being evacuated to another city or town,” McKenzie explained. “We'll then help them find the closest clinic and schedule them there.”
The company's IT systems contain all the medical information for a given patient, and these records can be pulled up at any DaVita clinic in the country. If the patient ends up at a non-DaVita-operated facility, the company provides that facility with the necessary patient information.
Dr. Kopp described a similar federal system that was put in place during Hurricane Ike. Information on all evacuees who were evaluated at federal medical stations (special-needs shelters) was entered into a single, integrated electronic medical record system. The data were uploaded to a nationwide server every few hours, making it possible to track the status and location of those evacuees—all of whom had significant medical problems, including ESRD.
At Fresenius, Numbers said, “We set up a toll-free patient emergency line and give that number to patients, particularly in hurricane zones and coastal areas. Our call center answers that phone 24 hours a day during a disaster.”
As soon as a patient calls in, the operator can provide the address and phone number of the closest dialysis center so the person can arrange to get there for treatment.
In 2008, DCA implemented its own toll-free number. A corporate staff member receives the calls, and each facility administrator then tracks his or her respective patients throughout the crisis.
In the 2007 CJASN report previously cited, the KCERC called global positioning system (GPS) devices in cell phones “an intriguing approach to maintaining contact between patients and dialysis facility staff.” The authors contended that such a system could be readily adopted by a dialysis unit to track the movements of patients—and perhaps staff—after a disaster and direct first responders to transport those in need.
“Always evacuate”
If you're a Fresenius patient, you will always be urged to evacuate when a hurricane threatens. “A dialysis patient may think, ‘I can't evacuate because I won't get dialysis,'” Numbers said. “We educate them all [so they know] that isn't the case. They should want to evacuate because then we can take care of them. It's much harder when people don't evacuate to try to keep a dialysis center open.”
Case in point: When Hurricane Gustav blew through Louisiana late last summer, people evacuated because of the Katrina experience. “And it was not a very bad situation, dealing with all those evacuated patients, because they went to locations where facilities were open, water was working, and power was up, and they were fine,” Numbers related. “Contrast this with Hurricane Ike, which came through Texas—Galveston in particular. Patients did not have the same recent Katrina experience, and some didn't evacuate because they thought they needed to be near their dialysis facility.” In Beaumont, Texas, the mayor called for evacuation, but 17 Fresenius patients stayed. “That's a problem for me,” Numbers admitted. “My choice is, get them out of there somehow or support them there. That's a decision I need to make at the time: Do I have enough resources to go in and open dialysis facilities in an evacuated town where nobody should be?”
Providing for employees
When Numbers and his team decided they could open the Beaumont dialysis facilities, they had to arrange for generators and the diesel fuel on which they run, generators for the homes of employees and gas for their cars (because the gas stations had no power), as well as food and ice for them. Numbers also had 30 recreational vehicles sent for staffers who had come from elsewhere to Houston, Galveston, and other affected regions to help out. “We had about 100 people on site within 48 hours of the storm.”
Approximately a third of those people were security personnel. “They're a very important part of our program,” Numbers reported. “When you open a dialysis facility in a mostly evacuated town that has no power and no water and you're handing out gasoline and generators, food, and ice, you are a target because you're the only light on in the neighborhood. I want my staff to feel safe when they come to work, so I station guards at all those locations. We typically use armed guards, and they make it known visibly that they're securing this dialysis facility.”
Physicians can—and do—help
DaVita's McKenzie admitted that it can be a challenge to get clinic staff in certain regions to devote the needed time to advance emergency planning. “We get a lot of attention in Florida, Louisiana, Texas—states that have had major problems over the last few years-- and we are much more thoroughly prepared at a local level. But sometimes it's difficult in other states to get people's attention about disasters that they've never experienced. We continue to train, education, and become more prepared nationally.”
Nevertheless, McKenzie and Angie Kurosaka, BSN, RN—McKenzie's emergency-management team colleague and DaVita's vice president of operational support—are quite satisfied with physician response to their efforts. “Our physicians want to know what the plan is and how we're taking care of the patients,” Kurosaka said. “They are very aware and interested.”
According to Kurosaka, the medical director at each DaVita dialysis clinic works with the local team in preparing emergency plans and instructing patients to pack a three-day diet (in case they're unable to obtain dialysis) and all their necessary supplies. After the event, the doctors are willing to help locate patients and have an interest in knowing where their patients are. “In my experience after hurricanes Katrina and Rita, the physicians were very involved and actually assisted us in finding patients. They wanted to know the patients were safe.”
Numbers, too, had high praise for the nephrologists he has worked with during emergencies. “I've found the physicians in these disaster situations to be phenomenal. They show up instead of running away—they come to the disaster zone, they come to the dialysis facility, they come to their office, they come to the hospital.”
In turn, the nephrologists can gas up their cars at the Fresenius staging area so they can continue to tend to patients when gas is otherwise unavailable or avail themselves of other supplies. Numbers and his team stay in touch with the physicians regarding how many shifts the dialysis clinic will operate, how the water-treatment system is functioning, and other such issues.
A local feel
In addition to emergency preparedness at the corporate/national level, the dialysis facilities of Fresenius, DaVita, and DCA all have individual plans. “One cookie-cutter process does not work for all facilities,” Zimmerman pointed out. “DCA is in seven states, and even within those states, the emergency plans vary due to locality, weather, and medical director.”
These plans cover such details as where outside the facility staff members should meet in the event the facility is evacuated and which radio or television station patients should tune into in the event of an impending storm that could require closure of the facility.
Whatever the scope or nature of an emergency, DaVita's Kurosaka has a one-size-fits-all piece of advice: “Preparation is the key in disaster planning. Regardless of the disaster, prepare, prepare, prepare—and then when you think you're prepared, do a little more.”
Calming Patients in an Emergency
Jeffrey B. Kopp, MD, of the NIH's National Institute of Diabetes and Digestive and Kidney Diseases, reiterated the Kidney Community Emergency Response Coalition's tips for fostering the emotional well-being of patients during a crisis. Reassure your patients by emphasizing the following points:
* Despite current hardship, things will improve.
* Experts are working together to solve problems.
* Information will be shared as it becomes available.
* Facility staff members genuinely care about patient welfare.
* Evacuees retain control over certain key aspects of their situation: mental attitude, interactions with others.
* Grieving is a normal response to disaster.
* There is a degree of normalcy amidst the chaos.
Source: Clin J Am Soc Nephrol. 2007;2:825-838.
The Government Weighs In
On April 15, 2008, the Centers for Medicare & Medicaid Services issued its final rule on conditions for coverage for end-stage renal disease facilities, including a requirement that staff be able to manage emergencies likely to occur in the facility's geographic area. The list of emergencies for which dialysis facilities must be prepared include but are not limited to fire, equipment or power failures, care-related emergencies, water-supply interruption, and natural disasters likely to occur in the facility's geographic area. Among other requirements, dialysis facilities must:
* Provide appropriate training and orientation in emergency preparedness to the staff. The training must be provided and evaluated at least annually.
* Provide appropriate training and orientation in emergency preparedness to patients, including who the patient should contact during an emergency.
* Provide an alternate emergency phone number if the phone is not being answered and/or the facility is not functioning during a disaster.
* Have a plan to obtain emergency medical system assistance when needed.
* Contact their local disaster management agency at least annually to ensure the agency is aware of the dialysis facility's needs in the event of an emergency.
In the event of a disaster or emergency, the dialysis facility must make every effort to contact the patient's physician prior to initiating dialysis in a special-purpose dialysis facility. The special-purpose facility is responsible for communicating with the patient's permanent dialysis facility regarding the patient's status, forwarding this information within 30 days if possible.
Source: Federal Register Vol. 73, No. 73, FR Doc. 08-1102 (
www.cms.hhs.gov/CFCsAndCoPs/13_ESRD.asp, accessed Dec. 12, 2008).
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