No matter what your political leanings, one thing we can all agree on is that the United States does not have enough inpatient psychiatric beds. De-institutionization of patients with psychiatric...
Perhaps no buildings are more dependent on electrical power than our hospitals. Almost everything that we do to heal and to cure ultimately depends on a reliable power supply and when that supply is interrupted, hospitals shift into disaster mode. I’ve been through several hospital power outages over the past 30 years, ranging from a few minutes to many hours; this is what I have learned.
Where does the hospital get its power?
Fortunately, there are multiple redundant power sources in hospitals, from the main power feed from the local electrical grid, to back up generators, to back up batteries on pieces of equipment. In an optimal situation, a hospital will have 2 independent feeds from different parts of the electrical grid so that if there is a regional power failure affecting one area, power can be drawn from the second feed to ensure a steady electrical stream.
Most hospitals will also have a back-up generator, often run off of diesel fuel, that can kick in within seconds of a loss of electricity from the regional power grid. However, the back-up generators can usually only supply a fraction of the normal power needs. This results in “emergency power” circuits in the hospital that are usually indicated by red electrical sockets (as opposed to the standard white sockets that are connected to the regular power grid).
Hospital electrical systems are unique
Despite the systems of back-up power, sometimes power can be lost. One of the reasons for this is that most hospitals are made of buildings of varying ages. We tend to add-on to existing buildings or build attached buildings as patient demand grows, rather than raze the old hospital building and then build an entirely new one. This leaves us with electrical components of varying ages and the hospital’s electrical system is only as good as its oldest components. Additionally, the amount of power a hospital consumes is enormous and so fuses can often weigh 200 pounds or more, making emergency repairs more difficult and time consuming.
So what do you do when the power goes out?
One of the first priorities is to activate the hospital’s disaster command center that is used to coordinate responses too disasters. Most hospitals will do 2 or more mock disaster drills each year to practice for disasters. The disaster that you get is usually not the one that you practiced for but by doing drills, you can ensure that your communication channels and key response personnel are in place and can adapt to the specific needs of each unique disaster.
Intensive Care Units. The first priority is to ensure that life support equipment has power. This includes mechanical ventilators in the ICUs, dialysis machines, and operating room equipment. Modern ventilators have back-up batteries but older ventilators may not work when the power goes out so hospital staff need to immediately go and check on mechanically ventilated patients. An ambu-bag should be brought to every room with a ventilator being used. If telemetry monitors no longer work, then a nurse or respiratory therapist should be assigned 1:1 for ICU patients. There should be a flashlight in every room. If a sustained power outage is anticipated, then moving patients to a different part of the hospital that can serve as a surrogate ICU may be required. Ideally, this should be location that has existing cardiac monitors and medical gases such as the surgical post-op recovery room, the endoscopy suite, and the cardiac cath lab recovery area. It can be very helpful to bring in additional nursing staff, respiratory therapists, and physicians. When we had a recent power outage involving our ICU, we moved patients to the surgical recovery area and brought in 2 extra critical care physicians. One physician was in charge of logistics and maintained a white board in the recovery area to list which patients were going to different recovery room bays, which ones had ventilators, which ones had chest tubes with pleurovacs (needing wall suction), etc. This physician triaged the order of patient movement, directing which patient should be moved first and grouped patients together for optimized nursing and respiratory care.
Operating Rooms. Operating rooms are unique. Usually, there will be sufficient power available on the emergency power (red power socket) system to complete a surgery but air handlers may be on regular power with the result that an operating room may quickly exceed approved temperature or humidity thresholds. Therefore, assessment of temperature and humidity controls of each operating room need to be assessed to determine if they are working and if not, then surgeries in those ORs may need to be canceled. Usually, a surgical procedure that has already been started can be completed before temperature and humidity thresholds are exceeded; however, if a very long surgery is underway and the air handler for that OR goes out, then it may become necessary to complete a portion of the surgery, close, and then bring the patient back for a staged procedure the following day. Although this can result in significant surgeon and patient dissatisfaction, it is better than risking a surgical infection if thresholds are exceeded. Be sure to check refrigerators and freezers in the OR area because supplies like frozen bone grafts require very specific low temperatures.
Nursing units. Most patients on regular medical/surgical floors are not connected to life support equipment as occurs in the ICUs. However, a sustained power outage can affect patient comfort. Having lots of bottled water and extra blankets is helpful. Patients’ medical conditions can change so if the elevator power is out, it may be necessary to use stair sleds to transport patients off of a floor. Most hospitals maintain a supply of stair sleds but staff often are not experienced in using them. It is a good idea to practice use of these sleds during disaster drills.
Elevators. Each elevator needs to be assessed to determine who is in them when power is lost. Elevators with patients being transported between floors should be prioritized for rescue. Elevators containing staff and visitors can be assigned a lower priority for rescue. Be sure to get a cell phone number for someone in each elevator to keep in your command center.
Emergency Department. If power loss is anticipated to continue, then the ER should be placed on “divert status” which directs emergency squads to take patients to other hospitals in the area. You do not want patients with myocardial infarction, stroke, or trauma coming to the ER if you are not able to assess or treat them.
Pharmacy. The first task for pharmacy is to ensure that patients can get needed medications. Many hospitals will use a Pyxis system to keep medications on individual nursing units. If the Pyxis machines lose power and cannot be opened, then medications will need to be brought up from the pharmacy. The second step for the pharmacy is to preserve medication inventory. Most medications have specific temperature thresholds. Medications in freezers or refrigerators may need to be moved to alternative locations. If air handlers to the pharmacy area are affected, then temperatures should be monitored to ensure that thresholds for shelf medications not exceeded. Arrangements may need to be made for medication compounding at another location.
Laboratory. The hospital lab is particularly vulnerable when there is power loss. There are reagents in freezers and in refrigerators that can have very specific temperature thresholds. These reagents can be very expensive so prioritizing moving these freezers and refrigerators to emergency power sockets or portable generators is necessary. When we had to do this, we found that having a lot of extension cords in our facilities department really paid off (you can never have too many extension cords in a power failure!). Refrigerated blood products in the blood banking areas also need immediate attention. The chemistry and hematology analyzers have fairly strict temperature and humidity thresholds – as long as these thresholds are not exceeded, then the analyzers simply lie dormant until power is restored but if thresholds are exceeded, then the analyzers may be down for days while reagents are replaced, controls are run, and analyzers are checked and serviced. We brought portable air chillers into our lab that ran off of emergency power to ensure proper ambient air temperature when we lost power. This is especially important in the lab where freezers and refrigerators running on emergency power can generate a lot of heat that can quickly warm up the lab area. Once power is restored, it may take several hours to get the lab analyzers back on-line. It is very useful to have a contingency plan for the lab with a courier system and an alternative lab that can run samples. Don’t forget about blood gas analyzers – these generally have a back up battery supply and can continue to run for a short time in the event of a power loss. Because these machines can generally also do hemoglobin and basic chemistry tests, they can be an important resource and should be prioritized to connect to emergency power or a portable generator.
Fire safety. If power loss results in the hospital’s fire alarm system being off line, then you should contact the fire marshal. In most communities, it is the fire marshal (and not the hospital’s administrative staff) who decides whether or not a building needs to be evacuated due to power loss. If the fire alarm system is not functioning, then a “fire spotter” will need to be assigned to each floor of the hospital. This is a hospital staff member who is equipped with a flashlight and a cellphone or other communication device whose sole job is to constantly patrol that floor for fire or smoke and can report directly to the command center.
Radiology. CT scanners and MRIs are particularly susceptible to power loss. When these systems go down, it can take 1-2 hours to bring them back on-line and even longer if one of their fuses blow at the time of the power outage. This may require bringing in management-level personnel who are experienced with rebooting these devices. Most hospitals utilize portable x-ray machines that can run off of batteries. This can at least allow for basic x-rays to be performed. Power loss may result in an inability to transmit the images to the hospital’s PACS system for review by a radiologist but at least there is usually a monitor on the portable devices that permits x-ray review by an on-site physician.
Cardiac catheterization laboratory. The cath lab has equipment, medications, and supplies that have specific thresholds and attention to temperature and humidity in these areas is necessary so that medications and equipment can be relocated if thresholds are reached. Additionally, the imaging equipment in a cath lab can take a long time to reboot. Bringing in your hospital’s clinical engineering personnel is essential for bringing cath lab equipment, radiology equipment, and other electronic equipment back on-line.
Inventory. All kinds of supplies in the hospital have specific temperature and humidity thresholds. A typical hospital will have about $1 million of supplies in the operating rooms alone. If temperature or humidity thresholds are approached, then it may be necessary to relocate these supplies to other locations to prevent losses.
Food services. Patients need to eat and if the power to the kitchen goes out, then alternative food sources need to be identified. There are portable kitchens in mobile trailers that can be brought on-site to do food preparation. It is a good idea to know who to call for portable kitchens as part of regular disaster planning so that one can be brought on-site quickly if needed. Food inventory in refrigerators and freezers requires attention and either needs to be relocated to meet temperature thresholds or need to be disposed of. Don’t forget about refrigerators in nursing units and procedure areas that contain snacks and drinks as these will also need to be disposed of if temperature thresholds are exceeded. If there is a sustained power outage, then hospital staff also need to eat, particularly all of those who are staying past their normal shifts to attend to patient care and safety. Bringing in pizza, bottled water, and snacks for nursing units can really help maintain morale. Calling in a couple of local retail food trucks can also help.
Central sterile supply. Sterilized surgical instruments will have specific thresholds and if sterilized packages get condensation in them, then they will need to be re-processed. Have a contingency location for surgical sets and case carts so that they can be maintained within thresholds.
Security. When power is lost to monitoring cameras and to public area lighting, there is increased demand on hospital security staff. It may take bringing in additional staff for patrolling parking areas at night and for patrolling hallways and waiting areas to ensure staff and visitor safety. Many access doors in hospitals will have electronic locks and badge readers. Be sure to send someone out to manually raise bars in gated parking lots to permit cars to enter and exit.
Electronic medical records. These often seem like the bane of physician existence but when they go off-line, it can paralyze patient care. Fortunately, most medical record systems get turned off for maintenance on a regular basis so hospitals have contingency plans for using paper charting for orders, progress notes, etc. It turns out that one of the hardest things to do when the electronic medical record goes down is to discharge patients, for example, from the emergency room.
Morgue. It is the last thing that anyone thinks about but don’t forget about the need to maintain low temperatures in the morgue if the air handlers are down. Options can include bringing in a portable refrigerated truck or identifying an alternative morgue location.
Equipment that you will need
Some of the items that I have found to be particularly useful to have during a power failure are extension cords, portable temperature/humidity monitors, and flashlights. Extension cords can allow you to re-route refrigerators, freezers, and essential electronic equipment to emergency power sockets or portable generators. Flashlights are useful everywhere. Portable temperature/humidity devices are a great way to tell if you are approaching thresholds in places like the operating rooms, pharmacy, lab areas, and central sterile supply. Ideally, bringing in infection control personnel and arming each of then with a hand-held temperature/humidity device allows for constant rounding and monitoring of these areas. It is also a good idea to document the temperature and humidity at regular intervals in each location so that once power is restored, it is easy to determine if thresholds were exceeded and for how long they were exceeded in order to determine what inventory needs to be disposed of. Hospitals will also maintain a stock of portable 2-way radios for communication. We use these but I have found that I use my cell phone primarily. If the power is out for more than a couple of hours, having cell phone chargers on had can be helpful.
Hopefully, your hospital will never have a power outage but every hospital needs to prepare and practice for how to respond in case power loss occurs.
January 18, 2020