Houston's Medical Disaster
Response to Hurricane Katrina
Grand Rounds February 26th, 2008
Douglas R. Hamilton MD, PhD
Kieran T. Smart, MD
Family and Community
Medicine, Baylor
College of Medicine.
Agenda
• Hurricanes for Dummies
• Initial Medical Response
from Texas Trauma Service
Area-Q
• Evacuee Arrival
• Converting the Astrodome
into a Shelter
• Creating the Katrina Clinic
• Transitioning from
Emergency Care to
Community Health Care
• Conclusions and
Recommendations
Introduction
• Hurricane Katrina - one of the
costliest and deadliest natural
disasters in U.S. history, killing
1,836.
• 373,000 New Orleanians and
Gulf Coast residents to fled their
homes.
• The remaining residents sought
emergency shelter in the
Superdome and Convention
Center.
• Houston was asked on August
31, 2005, to provide shelter for
the evacuees.
• On September 1, 2005,
evacuees were transported to
Houston by bus.
FEMA News Photo
FEMA News Photo
The “phone call”
I was in Mission control
when Baylor
management called
asked if Dr. Smart and I
could help build the
triage capabilities for
30,000 people in 12
hours!
The Problem
• 40,000 hotel rooms rented
to persons with a
Louisiana address.
• 250,000 new guest
citizens in homes, hotels,
churches, motels, and
shelters.
• 250,000 persons
challenged our hospital,
clinic, and doctor office
infrastructure.
• 42,000 were coming by
bus within 12 hours.
Texas Trauma Service Area – Q Health Care Facilities
•
•
•
•
1,756 square miles
4.5 million residents
Houston Astrodome
34 municipalities
more populous than 23 states
• 2 x Level 1 Trauma Centers
• 1 x free standing pediatric facility
• 51 x acute care facilities with
emergency rooms
• 40 x non-acute/specialty hospitals
without emergency rooms
• The healthcare
infrastructure is
routinely saturated.
Houston
• 4th largest US city
• 4th largest Fire
Department in the
US serving a
population of 1.9
million over 617
square miles.
• Houston hospitals saw 1,750,000 ER patients in 2004
• On diversion more than 7.7 percent of the time.
• 3 HCHD hospitals and 10 community-based clinics,
serving a population of 1.2 million indigent persons.
CMOC
• The Catastrophic Medical Operations Center (CMOC)
became operational during the Katrina medical
response.
• The CMOC coordinated the transportation and
assignment of all patients within TSA-Q facilities based
on capacity and capability.
• The CMOC vectored approximately 1800 EMS
transfers (estimated) for Reliant City but was only able
to document 1093.
Upton LA, Frost MH, Havron DH. Operationalizing a regional unified medical
command. JHSEM 2006: 3: Article 7.
Houston Fire Department
• HFD EMS is comprised of….
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–
–
–
–
74 transport units (21 ALS and 53 BLS)
18 non transport paramedic squad units
120 first responder units (engine and ladder)
2400 state-certified EMT’s
270 state-certified paramedics.
These assets
are deployed
from 89 fire
stations with
3800 members.
Sources of Data
•
HCHD Hospital Emergency Departments (n=1,304)
– Ben Taub Hospital
– LBJ Hospital
– Quentin Mease Hospital
•
HCHD Hospital Inpatient Wards (n= 264)
– Ben Taub Hospital
– LBJ Hospital
– Quentin Mease Hospital
•
HCHD Hospital Outpatient Clinics (n=17,208)
– 12,219 - Katrina Clinic
– 4,989 - 10 community health care clinics
•
•
•
•
CMOC/EMS TSA-Q hospital transfers (n=1,093)
Paper-based medical records from shelter treatment sites (n=4,013)
BCM physicians and the Red Cross collected head count data manually
during evening ARC operations.
Over the last two years, interviews were conducted with
•
•
•
•
•
HCHD medical professionals
Red Cross workers
EMS agency personnel
Houston Fire Department personnel
Houston Police Department personnel.
Note: Admission data missing on the non-HCHD 93 healthcare facilities
inside Harris County
Evacuee Arrival Triage
• Evacuee triage was performed by
teams of physicians, nurses,
paramedics, or EMTs.
• Triaged 600 buses, 5 buses at a
time.
• Triaged 30,000 people in 48 hours.
• 7% of the patients were NONAMBULATORY
• Red Cross volunteers obtained
registration information as they
entered the shelters.
• Evacuees who were incapacitated
or in need of immediate medical
attention were transported to:
– Katrina Clinic
– One of 96 TSA-Q regional hospitals or
health care facilities.
FEMA News Photo
Other Harris County Facilities
•
Evacuees needing critical care
were air/evacuated to Ellington
Field south of Houston and
triaged in NASA’s experimental
aircraft hangers for transport to
University of Texas Medical
Branch Facilities (726 patients
triaged from 21 military transport
flights in the first 7 days.
• The George R. Brown Convention (GRB) Center registered
28,000 evacuees for services and sheltered 2,800 evacuees.
• GRB medical care was provided by:
• University of Texas Health Science Center at Houston School of
Medicine’s Family and Community Medicine Department
• University of Texas Medical Branch
• Evacuees who did not visit the large shelters were appearing
at doctors' offices and area clinics throughout Harris County.
Katrina Clinic
Encounter Funding
SELF PAY - NO ELIG
1%
MG MCARE NO CONTRACT
1%
MEDICARE
6%
BLUE CROSS TEXAS
0%
COMMERCIAL
1%
MEDICAID
17%
KATRINA REFUGEES
74%
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•
•
•
•
•
•
•
•
•
•
•
•
Celebrex
Prevacid
Septra DS
Glipizide
Levothyroid
Enalipril
Plavix
Glyburide
Metformin
Fosmax
Lanoxin
Metroprolol
Furosemide
EMS Transfers from Reliant City
500
450
CMOC EMS Transports
400
CMOC EMS Transport per 10000
350
300
Shelter EMS Transport per 10000
250
200
150
100
50
0
9/1/2005
9/2/2005
9/3/2005
9/4/2005
9/5/2005
9/6/2005
9/7/2005
9/8/2005
9/9/2005
9/10/2005
9/11/2005
9/12/2005
9/13/2005
9/14/2005
First 2 days of data based on EMS records, headcounts and registration records
Treatment in the shelters
• Rendered first-aid at treatment
site in the Dome and Center.
• Only over-the-counter medicine
was given out in shelters.
• Patients needing a prescription
or a detailed examination was
sent by golf carts or Metro Bus
to the Katrina Clinic
• This decision to keep the
Katrina clinic physically separate
from the main sleep areas of the
shelter was one of our best
planning decisions.
FEMA News Photo
• Four residents of the
Astrodome complex
died.
• All had chronic end-oflife disease.
– 2 died in hospital
– 2 died in the shelters.
• Most common health
problems:
– Uncontrolled hypertension
– Respiratory infection,
upper and lower
– Acute Gastroenteritis
– Medication refill
– Diabetes, uncontrolled
– Asthma
– Dermatitis
– Mental health problems
FEMA News Photo
Age distribution
65 and Older
9%
2 and Under
4%
3 to 6
4%
65 and Older
8%
2 and Under
5%
3 to 6
3%
7 to 12
8%
7 to 12
5%
13 to 18
7%
13 to 18
9%
19 to 65
66%
Katrina Clinic
2 and Under
2%
3 to 6
2%
7 to 12
3%
65 and Older
20%
13 to 18
5%
19 to 65
72%
ARC Shelter Triage
Shelter n= 4012
Clinic n = 12,219
CMOC/EMS n = 1,093
Peak n = 24,392
65 and Older
21%
2 and Under
4%
3 to 6
7%
7 to 12
10%
13 to 18
12%
19 to 65
68%
CMOC/EMS
19 to 65
46%
ARC whole population
Reliant City Nighttime Headcount
18000
16000
Astro Arena Population
Convention Center Population
Dome Population
12000
10000
8000
6000
4000
2000
Date
9/
14
/2
00
5
9/
13
/2
00
5
9/
12
/2
00
5
9/
11
/2
00
5
9/
10
/2
00
5
9/
9/
20
05
9/
8/
20
05
9/
7/
20
05
9/
6/
20
05
9/
5/
20
05
9/
4/
20
05
9/
3/
20
05
9/
2/
20
05
0
9/
1/
20
05
Headcount
14000
Katrina Clinic
•
Within 48 hours of initial operations, the Katrina Clinic, a 100,000square-foot state-of-the-art health center was created with:
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–
–
–
–
–
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•
•
Lab
X-ray
Pharmacy
Dental
Mental health services
65 examination rooms
Urgent care triage
Adult medicine
Pediatrics
Obstetrics and gynecology
Orthopedics
Emergency psychiatry.
Ophthalmology
The majority of illnesses involved medical specialties (Internal
Medicine, Pediatrics, Psychiatry and Geriatric medicine) with very little
trauma support required.
This finding is similar to the medical encounters documented after
Hurricane Andrew (Florida), Frederick (Mississippi and Alabama), and
Elena (Mississippi).
2/
7/
Date
20
05
/2
0
05
05
9/
14
/2
00
5
9/
13
9/
12
/2
0
9/
11
/2
00
5
9/
10
/2
00
5
9/
9/
05
05
05
00
5
20
20
20
00
5
1200
9/
8/
2
9/
9/
6/
9/
5/
9/
4/
2
05
05
00
5
20
20
200
9/
3/
2
9/
9/
1/
Patient Encounters
Katrina Clinic and ARC Shelter Encounters
1800
1600
1400
Katrina Clinic
1000
800
600
400
ARC Shelters
0
Waiting
Adult
Admissions
Incident
Command
Medical
Records
Psych
Lab
Quarantine
Annex
Geriatrics
Pharm
Peds
Radiology
Quarantine
Ophthalmology
Food
WC
Hospital Shipping/Receiving
Human Resources
Katrina Clinic Patient Encounters
150
Adult
Patient Encounters
125
100
75
Pediatric
50
25
•
•
•
•
9/16/2005
9/15/2005
9/14/2005
9/13/2005
9/12/2005
9/11/2005
9/10/2005
9/9/2005
9/8/2005
9/7/2005
9/6/2005
9/5/2005
9/4/2005
9/3/2005
9/2/2005
9/1/2005
0
Clinic activity peaked during daytime hours, but significant activity also occurred
at night.
2,700 medical professionals examined approximately 4,000 patients in the
Katrina Clinic over 36 hours;
749 patients were evaluated a 3-hour period.
570 mental health clinicians treated more than 4,300 cases.
• In the two weeks of Katrina
Clinic operations
– 12,219 patient encounters
were recorded
• 1,276 were for administrative
purposes only
• 4,791 were repeat visits.
– Prescriptions written for 9,215
patients numbered 16,622.
– 382 X-rays
– 155 ultrasounds
– 13,109 vaccinations were
administered.
Percent Patient Enounters by Time of Day
Percent Medical
Encounter by Time of Day
35
Percent of Encounters during the day
30
Shelter n= 4012
Clinic n = 12,219
EMS n = 1,093
25
20
15
10
5
0
00:00 - 05:59
06:00 - 11:59
12:00 - 17:59
Time Range
Time
Range
Adult Shelter
Adult Clinic
Pediatric Shelter
Pediatric Clinic
18:00 - 23:59
• Gastrointestinal outbreak
was detected in the
shelters on day 3.
• Diarrhea and vomiting
peaked at 200 persons
on Sept 5.
• Approximately 2000
persons with these
symptoms were seen
during a 10-day period.
• By the third day of the
epidemic Norovirus was
identified.
Date
20
05
20
05
20
05
20
05
20
05
20
05
20
05
20
05
20
05
9/
14
/2
00
5
9/
13
/2
00
5
9/
12
/2
00
5
9/
11
/2
00
5
9/
10
/2
00
5
9/
9/
9/
8/
9/
7/
9/
6/
9/
5/
9/
4/
9/
3/
9/
2/
9/
1/
Number of Encounters
Norwalk ‘Symptom’ Encounters
250.0
200.0
Katrina Clinic Encounters
150.0
Shelter Encounters
100.0
50.0
CMOC/EMS
0.0
• An observation/rehydration unit
was constructed, and a specially
designed isolation unit housed
patients after they were treated.
• Sanitation measures to limit the
spread of disease included
increased hand washing, use of
hand sanitizers, cleaning
contaminated areas with
chlorine, and increased
availability of sanitized showers
for residents.
Centers for Disease Control. Norovirus outbreak among evacuees from Hurricane Katrina-Houston, Texas. September 2005. MMWR. 2005;54:1016-1018.
• Liability advice was sought from members of the legal
community, Texas Trial Lawyers Association and the
Texas State Board of Medical Examiners.
• Over 2500 physicians and 3500 nurses appeared at
the registration desk.
Percentage and Absolute Numbers
of Medical Conditions
Medical Condition
Skin and Subcutaneous Tissue
Percentage of
Medical Conditions
Respiratory System
Nervous System and Sense Organs
Musculoskeletal System and Connective
Tissue
Medical Condition
SHELTERS
CLINIC
EMS
Mental Disorders
Gynecology and Complications of Pregnancy,
Childbirth & Puerperium
General Medical and Miscellaneous
Endocrine, Nutritional and Metabolic, Immunity
Shelter n = 4012
Clinic n = 12,219
EMS n = 1,093
Digestive System
Circulatory System
0
1000 2000 3000 4000 5000
Number of Conditions
Medical Condition
Skin and Subcutaneous Tissue
Percentage of
Medical Conditions
Respiratory System
Nervous System and Sense Organs
Musculoskeletal System and Connective
Tissue
Medical Condition
SHELTERS
Mental Disorders
CLINIC
EMS
60
80
Gynecology and Complications of Pregnancy,
Childbirth & Puerperium
General Medical and Miscellaneous
Endocrine, Nutritional and Metabolic, Immunity
Shelter n = 4012
Clinic n = 12,219
EMS n = 1,093
Digestive System
Circulatory System
0
20
40
Percent
Evacuee Patient Encounters Harris County and Reliant City
2000
Reliant City
Katrina Clinic (n = 12,219)
Shelter treatment sites (n = 4,013 recorded, 5513 estimated)
EMS/CMOC ( n = 1093 recorded, 1841 estimated )
1500
Number of Encounters
HCHD Hospitals
HCHD Hospital Emergency Departments (n =1,304)
HCHD Hospital Inpatient Wards (n = 264)
HCHD Outpatient Total (n=5040)
EMS Transfers Outside HCHD
CMOC EMS Transfers to Non HCHD
Hospital Emergency Departments
(n =1467 of 1841 estimated )
1000
Community Clinics
500
HCHD community Clinics (n = 4071)
Busses
Arrive
Shutdown of
Katrina Clinic
Katrina Clinic Rx
Refills needed
0
8/27/05
9/3/05
9/10/05
9/17/05
9/24/05
10/1/05
Date
10/8/05
10/15/05
10/22/05
10/29/05
11/5/05
Recommendations
•
Screening early for critical illnesses
•
– pediatric dehydration
•
Putting elders and families into
groups to make it easier for medical
and social service personnel to meet
their needs.
– delirium in fragile elders
– sundowning
•
•
•
Special populations
–
–
–
–
–
–
–
nursing home patients
Cancer
Diabetes
Dementia
psychiatric disorders
Chronic dialysis
methadone treatment.
•
•
Setting up a system to record
the names and identifying
information of any child, elder,
or disabled person taken from
the shelter facility.
BUILD a CMOC!!!!
Use Wireless Priority Service
for civilian medical personnel
(http://wps.ncs.gov/)
Use the local Community
Health Care procedures and
personnel.
ID tags at the disembarkation
point.
Questions
Now I know why the Star's shine briter over Texas
first is the people, and I guess, that's the way they see it also, only in a different manner,
anyway, the people, that's what this is about,
the only way to describe these folks is theyre Hearts as big as texas,
I'll Remember her forever, wherever I may go,
if it were possible, too describe an angel,
I'de bet my life he or she would be a texan,
….From, the Way's of our Lord-christ and myself and manny more,
Thank you,
May god bless all of you,
Brian Rousso