The successful functioning of a disaster plan should not depend on the presence of one or two individuals, notes Dirk Sosman, MD, chairman of radiology, New York Presbyterian Hospital, New York City, who was unable to exit San Francisco when the terrorist attacks occurred.

In the initial hours after two hijacked jetliners toppled New York City's World Trade Center towers, hospitals across Manhattan on that fateful mid-September morning found themselves besieged with injured survivors. There were so many wounded that a few hospitals could not accommodate all who sought treatment.

Such was not the case at New York Presbyterian Hospital. Thanks to a well-designed, much-practiced disaster plan, New York Presbyterian's 1,200-bed, level I trauma center on the campus of Cornell University in Upper Manhattan was able to provide emergency care for everyone transported in.

That is not to say everything about the disaster plan worked flawlessly. There were some glitches resulting from circumstances beyond the hospital's control, such as phone service disruptions and loss of access to that portion of the Internet providing external-only communication. Also, by late in the day, the winds began pushing smoke and stench from the destroyed skyscrapers toward the hospital, making it harder for some staffers to concentrate on their work.

Moreover, key personnel in the Department of Radiology were absent from the hospital when the disaster hit. Dirk Sostman, MD, FACR, radiologist in chief and department chairman, was in San Francisco attending an ACR conference on September 11, the day of the attack, and was stranded there for the next 72 hours. The department's vice-chairman was in Washington, DC. And senior radiology administrator Rick Perez, RT, at home in south Long Island, had weeks earlier arranged for that day off in order to celebrate his birthday.

YEARS IN THE MAKING

New York Presbyterian Hospital's efforts to have a formalized plan of action in place for dealing with disaster extends back at least two full decades. "Since you never know when disaster will strike or what form it might take, simple common sense and prudence dictate that a hospital have a disaster plan that's comprehensive and yet flexible enough so you can respond to almost anything thrown at you," says Sostman. "In the early 1980s, we began developing our blueprints for dealing with disaster because we were concerned that it would be too easy to lose control of a situation if we were to continue relying on informal and loosely structured procedures as we had until then."

Building a Team

From left, Rick Perez, RT, senior radiology administrator, Andrew T. Oster, Jr, supervising technologist, and Ed Quest, ultrasound technologist.

The starting point for development of the plan was the creation of a disaster-preparedness team. Reporting to the hospital's Institutional Safety Committee, this team consisted of the heads of the departments most likely to form the front line of response during a calamity-the emergency department (ED), nursing, pharmacy, laboratories, paramedics, and, of course, radiology.

"It was decided that each department would produce its own disaster plan," says Perez. "Then, those individual, department-level plans would be reviewed by the full team and modified as necessary in order for them to be melded into a single, enterprise-wide plan."

"Each department received guidance and parameters from the disaster-preparedness team, which kept us all moving in the same general direction," says Perez. "There also were opportunities for the department heads to meet and compare notes."

The design of the radiology component of the plan was affected by seemingly esoteric-but nonetheless important-considerations. One of them, says Perez, was the distance each member of the staff lived from the hospital.

"We had to take into account things like how long it would  take the radiologists, technicians, and support staff to get back here if we had to call them at home in the middle of the night, and what we could do to expedite their travel if the roads they normally would be driving on to the hospital were blocked," he explains.

Another consideration dealt with loss of electricity. Years later, this would become an increasingly pivotal issue owing to the radiology department's conversion to a near-totally filmless environment.

"We were among the first hospitals in the state to deploy full PACS," says Perez. "That was in 1997. Today, PACS-plus our radiology and hospital information systems, which are fully integrated with one another and with our enterprise electronic medical record system-are at the very heart of our operations. Lose those because we have no electricity and we are in serious trouble.

"So, we asked ourselves, if there were a disaster that wholly disrupted our digital environment, could we go back to functioning with just paper and film? Would we even know how to go back to paper and film? These were potential problems we had to anticipate and address in the disaster plan."

The PACS performed admirably during the crisis period. "We did not have any issue with PACS," Perez confirms. "PACS runs on the hospital fiber network and is redundant so that we always have a path to send an image. If the path was to be interrupted we could rely on the acquisition and QA workstation to see data at the modality instead of the workstation. Images are stored in multiple places and also kept on the modalities so that, if need be, we would resend the images or reformat off the capture device. We also have multiple storage devices and redundancy at the archive level so chances of losing an image is almost  impossible."

"The need to return to film is always a possibility and we maintain a few daylight processing units as well as a dark room,  just in case," he continues. "We also keep a short supply of film that we anticipate would last as long as [the network is down]. There are also [available] a limited number of multiviewers to read films. Additionally, we have handheld battery dictation units as a backup for the reporting of cases, and the use of wet read slips to get results out while we wait to transcribe the full report."

As senior administrator for the department, responsibility for developing the radiology component of the disaster plan fell to Perez. However, he did not rely solely on his own knowledge of how things work in the department in order to formulate it.

"It would have been a mistake for me to not talk to key people in the department-the supervisors, the managers, the residents, the physicians," he says. "There were things I did not know, and there were things I knew but had forgotten. Gathering the input of others in the department helped me come up with a plan that could really cover all the bases."

EMERGENCY DEPARTMENT'S CALL

Refinements to the radiology component of the disaster plan have been made from time to time as warranted by circumstances or newly perceived dangers. For example, the plan underwent extensive revamping in the 24 months leading up to Y2K on January 1, 2000.

"The disaster-preparedness team meets quarterly to discuss various concerns in light of developments going on in the world and here in the enterprise," Perez says. "Often, that means having to update the plan at the department level. Any time a department's plan is revised, the disaster-preparedness team has to review it and approve it. Then, it has to be reviewed and approved again by the Institutional Safety Committee at one of its regular monthly meetings."

Perez declines to hazard a guess as to how many man-hours he and others have invested in the creation and periodic revamping of the hospital's disaster plan.

"It's a substantial commitment of time, that's for certain," he says. "I would estimate that this project occupies as much as 15% of each department head's total job time from one year to the next."

Every so often, the hospital conducts disaster-readiness drills. The purpose is to test how well each revision will work, but also to keep staff confident about their ability to respond during a real disaster.

In most situations, the disaster plan becomes effective when the hospital's ED figuratively pushes the alarm button upon receiving word from local, state, or federal government officials to momentarily expect an extraordinarily large volume of trauma patients. Sometimes, the call never comes, but the ED is nevertheless alerted to a pending tsunami of cases by TV and radio news coverage of a local disaster in progress.

According to Perez, an announced disaster sets in motion a sequence of actions within the hospital that allows the decks to be cleared for receipt of casualties. First, the hospital begins shutting down non-essential operations and opens a command center from which the overall disaster response is coordinated.

"The department heads meet in the command center as soon as it goes operational," says Perez. "At this point, they are briefed on the nature of the crisis by senior administrators of the hospital and told which parts of the disaster plan to implement."

After receiving instructions, the department heads disperse to their respective areas within the facility. At regular intervals-or more often as conditions dictate-the department heads deliver status reports to the hospital administrators back in the command center.

"The hospital officials in the command center have the big picture, so they are able to redirect resources if, for instance, the ED begins to experience trouble processing patients quickly enough to keep up with the inflow of injured," says Perez.

In the radiology department, all outpatient studies that have already been started are completed and the remainder of those on the schedule are suspended for the duration of the crisis. In effect, the outpatient section closes down, Perez indicates.

Meanwhile, the inpatient section of the department cancels all of its nonurgent procedures, except for those in progress.

"This frees the staff and resources from those two sections to focus on the disaster," says Perez. "As soon as they've shut down their outpatient and nonurgent inpatient activities, the staff begins moving transporters from the main department area into a predefined staging position in the ED.

"The angiography rooms, the CT scanners in the main department, the MRIs-these would all continue handling urgent inpatient work, but would be on high alert to take on and give priority to disaster-related cases, if necessary."

Off-duty radiologists and technologists are summoned back to the hospital. Those whose shift is ending remain on duty until relieved.

Disaster victims, as they arrive, are assigned a unique patient identifier number exclusive to this particular disaster and are triaged at the door of the ED. The cases that require only simple radiography are imaged just inside the ED door by means of portable x-ray machines. Those cases that need to be examined by CT are wheeled into the ED's radiology area. The ones for which only MRI and other sophisticated forms of imaging will do are transported to the radiology department's main floor, Perez tells.

The step-by-step details of the disaster plan are spelled out in a manual, which occupies a three-ring, loose-leaf binder.

"A copy of the manual is placed in the radiologist reading rooms and in every supervisor's office," says Perez. "The manuals don't sit around unopened, gathering dust on the shelf. This being New York, things happen often enough-snowstorms, what have you-that we have reason to refer to them frequently."

The radiology department experiences a substantial turnover of staff from year to year, which makes it an imperative to provide ongoing disaster-preparedness training and drilling.

"The disaster plan is part of each new person's job orientation," says Perez.

HARD DAY'S NIGHT

Within minutes of the first hijacked jet plowing into its target on the morning of September 11, Perez was on the phone from home with a vice president at the hospital. But even before Perez had hurriedly finished dressing and hopped into his car, the radiology department was moving into disaster operation mode.

"The attack on the World Trade Center unfolded at the start of a normal business weekday," says Perez. "Consequently, we in the radiology department-as was true of virtually every other department in the hospital-had most of our key personnel and an almost full complement of support staff on hand and in place to respond to the disaster.

"That played a big part in our being able to keep up with the volume of injured arriving in the ED throughout the day."

By 7 PM, the flow of casualties slowed appreciably. Word from the scene of the catastrophe indicated there would not likely be many more to come, even though rescue workers were only beginning the hunt for survivors beneath the debris of the demolished buildings. Perez decided he could begin letting some of his staff go home for the night.

However, staffers who lived outside Manhattan found that roads, bridges, and ferries leading away from the city were closed. This was a development anticipated by the hospital's disaster plan, and the radiology department had already arranged temporary lodging nearby for those who could not get home.

Throughout the day, distractions abounded. Fortunately, few of the staff allowed themselves to be derailed by them.

"That was particularly remarkable since many of our staffers in the radiology area attached to the ED were acquaintances of the paramedics who had gone to the World Trade Center to assist in the rescue effort," says Perez. "TVs and radios were on, so everyone knew that the towers had collapsed. There was enormous concern among the staff about the fate of their paramedic friends. On top of that, we also had staff with family and friends who worked in the towers, and their concern was even greater."

To alleviate this mounting level of anxiety, Perez assigned a few of his people to the task of obtaining from police, fire, and other disaster-response units the names of people who managed to escape the buildings or who had been rescued. Those names were checked against a list of relatives and friends supplied by worried staffers. As soon as it could be confirmed that someone on the list was safe, that information was announced.

"Too often, there was just no word on the fate of people on the watch list," says Perez. "Toward the end of the day, when there was still no news about the missing, we offered those concerned staffers the opportunity to be relieved so they could go look for the person they were waiting to hear about. Believe it or not, most of them declined and asked to stay on and keep working. I think they realized that there was nothing else they could do at that point but help those that had survived and were here in our hospital."

REEVALUATION TIME

The disaster plan was kept in effect until Thursday morning, September 13. At that time, the hospital began resuming normal operations, but remained on high alert for some time thereafter in anticipation that additional survivors would be found.

Standard procedure at New York Presbyterian calls for an exhaustive critique of disaster-plan performance following each incident, Perez reports. Thus, by the end of October, the hospital's disaster-preparedness team had formally convened twice to discuss the evident strengths and weaknesses of the plan. However, no action had by then been taken to alter or otherwise amend it.

"There will be ample opportunity for revision in the months ahead," says Sostman.

Perez says some of the reassessment discussions have centered on ways to harden the hospital's telecommunications systems.

"Many of the phone lines in New York City were routed through central exchanges located in the immediate vicinity of the World Trade Center," he explains. "When the buildings collapsed, those phone company facilities were disrupted. As a result, we had a lot of trouble calling out. The external access to the Internet was completely gone. Cell phones were useless. Fortunately, we didn't lose internal phone service or access to our intranet. We also could stay in touch with the outside via the 911 emergency phone system, which stayed up.

"But what we had left of the phones was so heavily taxed that you could not easily get through to anybody in the other departments. We had to resort to sending messages within the enterprise by courier. I myself walked more miles in that one day than I think I did in all the days of my life put together."

One of the preliminary and nonbinding recommendations is to distribute handheld two-way radios and pagers to key personnel so that use of phones can be minimized, Perez discloses.

The most obvious flaw noticed by Perez dealt with staging the staff. "At 8 o'clock that first night, we had so many people staged and waiting in one area-inside the ED-that they were getting in the way of those who already had tasks to perform," he recalls. "I realized that we needed to change the plan so there would be a radiology-specific subcommand center set up. This center would be where the staff would go to await assignment. I envision it being located in our main department area. This would prevent unassigned staff from crowding into a high-traffic hot zone like the ED."

Sostman, who was stranded in San Francisco the entire time the hospital was in disaster mode, says, "That the plan functioned smoothly despite the inability of some key personnel to be present is a tribute to its excellent and well-thought-out design. It was a plan not at all dependent on any one or two individuals for its success.

"The sense of the reevaluation meetings we've had thus far is that the systems we had in place did, by and large, work exactly the way they were supposed to. The staff and the supervisors followed the plan and did a great job."

Adds Perez: "With a disaster plan, you try to prepare for the worst while hoping for the best. And the best you can hope for is that you never have to use your disaster plan. Unfortunately, we now live in a time when it's more and more likely the plan will be used."

Rich Smith is a contributing writer for Decisions in Imaging Economics.