Hospitals and hospital pharmacies across New York and New Jersey prepared for the worst as the massive tropical storm named Sandy moved up the Atlantic Coast in late October, gathering force and threatening to take a sharp turn into one of the world’s most populous metropolitan areas.

When the storm finally struck on Monday night, Oct. 29, the devastation exceeded even the gloomiest projections. More than 100 people lost their lives, countless homes were flooded or destroyed by the tidal surge and millions of others were plunged into darkness, many for weeks.

Four Manhattan medical centers—NYU Langone, Bellevue, New York Downtown and Manhattan VA—were forced to close and evacuate more than 1,000 acute-care patients after rising East River tidal waters flooded lower floors and basements, disrupting back-up generator service and destroying many millions of dollars’ worth of medical equipment, medications and supplies. For NYU Langone alone the cost of restoration was put at $750 million to $1 billion.

image
Staff at Bellevue Hospital, in New York City, carry a baby down a stairwell during the hospital’s evacuation on Oct. 30, (Sheri fink/ProPublica)

In New York’s outer boroughs, Sandy wreaked havoc on shoreline homes and medical facilities. Extensive flooding forced Coney Island Hospital, on Ocean Parkway in Brooklyn, to close and transfer patients elsewhere, including Maimonides Medical Center, in Brooklyn, which remained open throughout the crisis as a go-to facility for people affected by the storm. Maimonides also opened its doors to patients evacuated from NYU Langone, New York Downtown and Bellevue, as well as local nursing homes that lost power.

Victor Cohen, PharmD, BCPS, GCP, the clinical pharmacy manager for the Department of Emergency Medicine at Maimonides, experienced Sandy’s power firsthand when the storm-driven tidal surge flooded his Bergen Beach neighborhood in the Mill Basin section of Brooklyn. Like his neighbors, he and his family hustled into their car to escape the rising water, but the car died in the middle of the street and they had to retreat to the highest floor in their house. “There was about two feet of water in the backyard with objects floating about,” he said. “Some water flooded the basement. We shut everything down. We were afraid of fire.” Fortunately, his house never lost power, but did need to have its gas line replaced on an emergency basis.

Maimonides Meets Surging Demand for Services

image
The Brooklyn neighborhood (above and below) of Victor Cohen, PharmD, was hit hard by hurricane Sandy—as was his hospital, Maimonides Medical Center.
image

In anticipation of the storm, Maimonides had ample medication supply on hand, according to director of pharmacy Fredrick Cassera, RPH, MBA. Thus, even the failure to receive the regular Tuesday shipment from AmerisourceBergen’s Pennsylvania distribution center never adversely affected patient care, even as more and more patients were being transported in from other facilities, Mr. Cassera said. By the next day, he noted, the wholesaler resumed shipments from its Boston warehouse.

The patient surge did mean that more of the medical center’s pharmacy team of about 100 pharmacists and technicians had to be called into action compounding IV medications and parenteral nutrition solutions, Mr. Cassera said. A major drug recall from Ameridose during this critical period also contributed to citywide drug shortages and the need for stepped-up activity. “Our [USP Chapter] <797>-compliant IV room was on all four burners compounding IVs to get the production levels up,” he said.

“We were very fortunate,” Mr. Cassera added. “We have a lot of dedicated staff that came in despite the conditions. Our administration made provision for alternate methods of transportation, like a car service, and they provided sleeping accommodations and meals. They really went into full mode to support us.”

The pharmacy also supplied discharge medications to patients from some closed hospitals as well as the medical center’s own patients who needed to have prescriptions filled or refilled. Maimonides gives all patients the option of receiving a supply of their discharge medications before leaving the hospital. “Approximately 20% of patients never fill their prescriptions,” Mr. Cassera said, “but by offering them that option at discharge, we feel very confident they are going home in a much safer environment.”

In Maimonides’ crowded emergency department (ED), the number of boarded patients awaiting transfer to inpatient units began to mount as evacuees from other hospitals and nursing homes kept arriving, said David Zimmerman, PharmD, a postgraduate-year 2 emergency medicine resident, who oversees a resident pharmacist team staffing the satellite under the direction of Dr. Cohen. Dr. Zimmerman said the ED normally accommodates anywhere from 10 to 12 boarded patients a day. “During the hurricane,” he added, “the number of patients being boarded increased to 50 to 70.” Some remained in the ED as long as three days. “Some of the areas of our ED turned into virtual internal medicine floors, where we had to supply medications on a daily basis,” he said.

The number of patients needing kidney dialysis also rose as local dialysis centers lost power. “It’s not uncommon for [the ED] to have one or two dialysis sessions a day,” Dr. Zimmerman said. “We were running dialysis sessions 24/7. We had to have nurses and technicians stay overnight to continue the sessions.”

The ED also experienced a sharp rise in individuals seeking methadone because their regular clinics were closed. “There were anywhere from five to seven times more patients coming in for methadone than usual,” Dr. Zimmerman said. “We had to call and verify their dosage and contact their prescriber before we could give a dose.”

Putting Patients First At Barnabas Health

New Jersey health care facilities also were severely tested by the storm, but most managed to remain in service and provide patient care as well as accommodate the inflow of local people affected by the storm. Barnabas Health’s six acute-care medical centers and one behavioral health acute care medical center all went on emergency generators, just as the storm cut off power to surrounding communities.

Heavy medication ordering on Thursday and Friday by Barnabas pharmacies tracking the storm’s progress meant that none of the medical centers came close to medication shortages due to distribution interruptions, said Indu Lew, PharmD, the corporate vice president of education and research at Barnabas Health.

“The directors of pharmacy ensured that we would minimally have a three-day supply of medications. The wholesalers called us on Sunday to make sure we would order before 5 p.m. in order to get deliveries even on Monday,” she said. “We have centralized parenteral nutrition processing, so we made sure we doubled up on our orders on Monday morning to cover Tuesday and Wednesday. And by Tuesday and Wednesday, we started getting [the required] deliveries.”

Describing how the storm directly affected many of the health system’s staff, Dr. Lew noted that many staff members “lost their homes, everything they owned. It’s really tragic.” But she said the administration stepped in to help, allowing employees to give back vacation days and donate the dollar value to help people who were affected. “We have 20,000 employees,” she noted. “So if everyone gives a day, we can make a huge impact. Administration established programs for housing and transportation allowances, as well as provided meals in our cafeterias to employees and their families.”

Intensive prior planning and constant communications during the storm and afterward helped to maintain business as usual even as communities all around were being devastated, Dr. Lew added. “The pharmacists, technicians and all of the staff really stepped up,” she said. “They stocked up and people worked double and triple shifts without complaint. They did a lot to make sure that patients were taken care of because they knew that what was happening was bigger than all of us.”

The gasoline shortage crisis that hit in the wake of the storm had little effect on Barnabas physicians, nurses and licensed practitioners. Barnabas made special arrangements with certain stations that still had operating fuel pumps to provide gas to the medical centers’ essential staff. In Toms River, one station reserved a pump for employees at Barnabas’ nearby Community Medical Center.

NYU Langone Pharmacy Copes With Massive Shutdown

image
NYU Langone Hospital, in New York City, had to evacuate many of its acute-care patients to other city hospitals due to the effects of hurricane Sandy.

Two weeks after the storm, NYU Langone was still at an early stage of recovery. Arash Dabestani, PharmD, the senior director of pharmacy, described some of the work that a core group of pharmacists was doing to prepare for the day when the huge medical center would return to full operation. Others among the 100-member staff of pharmacists were scattered to different locations, including some to other pharmacies in the NYU complex and others to several hospitals needing help to manage the influx of NYU Langone patient evacuees.

Lights and telephone service had just been restored to the third-floor pharmacy earlier that day, but with the pharmacy system available on a read-only basis and no inpatients to service, the staff shifted attention to other tasks. “We’ve spent easily 75% of our time the last couple of weeks doing nothing but discarding medications that were damaged and securing our other stock,” Dr. Dabestani said.

One of the chief concerns, he said, was to find a suitable location for the medical center’s investigational drug service. “We have many, many patients on research protocols who need to get their medications.” Fortunately, space was available in a newly constructed nearby NYU building. “This is a brand new pharmacy that has occupancy permits, but we haven’t moved in there yet, so we just moved them there for the time being.”

‘Virtual Beds’ Aid in Disaster Response

Maimonides Medical Center was able to handle the surge of patients from hospitals and nursing homes forced to close in part because of a “virtual bed” system that it has in place for just such emergencies.

“When the need arises, as it did with Hurricane Irene, we have the ability to add beds to each patient area,” Mr. Cassera said. “Every medical/surgical unit has the potential to accommodate up to five additional beds.”

The medical center also can activate virtual beds in larger areas that go unused during an emergency, such as the ambulatory surgery or endoscopy units. The virtual beds are part of Maimonides’ automated computer system, he said, so if they are activated, the additional medication demand can be handled easily by the automated cart-fill system and medication carousel.

—B.B, J.B.

Dr. Dabestani also has spent time training hospital staff for a switch to the Epic enterprise-wide management system. “Epic includes everything from patient billing and registration to medication profiles. This is a big deal, a very big deal. The goal-line date is still scheduled for Dec. 2, but the main hospital won’t be going live, so we’re going to use this downtime to make sure everybody is trained and tested.”

Days after the storm had passed, Mr. Cassera said Maimonides Medical Center was “still in a surge mode,” with Coney Island and the other affected hospitals perhaps months away from reopening. “Many of my staff were also affected,” he said. “They’re dealing with this catastrophe on a personal level and yet maintaining their commitment to patients.”