Facing Disaster
By Beth W. Orenstein
Radiology Today
Vol. 20 No. 10 P. 22

Disasters come in many forms, and radiology departments need comprehensive plans to handle them.

Last year, the Federal Emergency Management Agency (FEMA) declared 124 disasters—earthquakes, hurricanes, tornadoes, floods, blizzards, tidal waves, fires—down from the 137 it declared in 2017. As of late August, FEMA has declared 63 disasters, which is on pace to end 2019 with fewer than the previous two years. But disasters are hard to predict, and there’s a sense among the scientific community, thanks largely to climate change, that natural disasters are on the rise. None of these FEMA numbers reflect mass shootings, acts of terrorism—domestic or otherwise—or cybersecurity threats, which can also have widespread effects on health care.

When disasters happen, “we expect our health care organization to be there for us,” says Wendy J. Stirnkorb, CRA, RT(R)(MR), MRSO, MRSC, director of imaging services for Regional West Medical Center in Scottsbluff, Nebraska. “We need them.”

Since 1996, when HIPAA was enacted, all health care providers have been required to plan for emergencies so that they can return to normal operations in the shortest possible time frame. Agencies that accredit hospitals and standalone facilities also require those seeking and renewing accreditation to have disaster recovery plans in place, says Stirnkorb, who spoke about disaster recovery at the AHRA 2019 meeting in Denver in July.

“Unnatural disasters are as much a concern as natural disasters,” Stirnkorb says. Since her talk, there has been a spate of terror attacks, cyberattacks, and active shooter incidents in the United States and around the world. “People need to be aware,” she says.

Stirnkorb says, given the climate situation and recent events—eg, the Walmart shooting in El Paso, Texas, and the night club shooting in Dayton, Ohio, that left dozens dead in the same weekend—it’s important for health care providers to take disaster planning seriously. That means not only having a disaster recovery plan but also being able to implement it.

“You have to have a plan, and you have to be able to deploy it,” she says.

Where to Begin
A good place to start, Stirnkorb says, is analyzing what your major risks might be. For example, she says, Californians might be more concerned about wildfires and earthquakes, while those along the Gulf Coast have to think about flooding and people in the Midwest about tornadoes. “The plan you create,” she says, “has to include how you can continue to care for the patients you currently have in house, as well as those you might be expecting due to any one of these events.”

An executive team that includes the hospital chief operating officer and other department heads will likely have to decide whether to remain open and, if so, what services will be offered during the emergency, Stirnkorb says. In the imaging department, “you have to think about what modalities you will staff,” she says. She adds that some equipment may not be functioning, and some may need to be moved to operate.

In many hospitals, the radiology department is on the ground floor or, even worse, in the basement. “If you’re looking at a flooding situation, you can’t move your MR or CT scanner or nuclear medicine cameras to higher ground,” Stirnkorb says. “But you can plan on a secondary location on a higher floor for ultrasound and portable X-ray equipment so you can still maintain imaging services.” Also, she says, there needs to be a plan for protecting those million-dollar machines from flood damage.

Nuclear medicine, mammography, and MR staff may need to be reassigned to modalities that are operational, Stirnkorb says. Frequently, she says, in smaller facilities, staff are cross-trained and reassignment isn’t a problem. “In larger facilities, this might mean those team members are utilized elsewhere,” she says.

Whatever decisions about staffing and staying open are made, they have to be communicated to all, Stirnkorb says. It’s also critical that your facilities department be part of the disaster planning process so all utility needs can be met, including the power requirements for imaging equipment, she says. If the electricity is out and the internet is down, mobile phones and text messages may not work either. The plan has to include what staff will do to get updates about where and when they need to be somewhere, she says.

A Comprehensive Plan
Not only is it necessary to have a plan for caring for patients but administrators also have to consider how to care for staff, Stirnkorb says. Staff members likely have family in the area, and the safety and wellness of those they may be required to leave at home, who could be in the path of danger, needs to be addressed, she says. Staff may not be able to give their full attention to patients if they’re worried about their loved ones’ safety. Will the hospital or facility provide shelter to staff’s family? What about their pets? These are questions that should be addressed in any disaster planning process and communicated to staff prior to an actual event, Stirnkorb says.

“People in the medical field, including radiologists and technologists, want to do the best by patients,” Stirnkorb says. “Still, we also have families of our own to take care of. Making sure our families are safe so we can focus on our patients is an important part of disaster planning, too.”

If staff have long shifts, it’s important to plan ways to keep them fresh. Where will they eat, sleep, and shower? It’s often a good idea, Stirnkorb says, to have two teams, Team A and Team B. “The A team is on for so long, and the B team rests. Then the B team is on, and the A team goes to rest.” Having a workable plan is important in situations where the disaster might last a few days, she says. “Sometimes, for instance, hurricanes or blizzards might affect your facility for more than a few days.”

Just having a disaster recovery plan is not enough, though. “If it sits on the shelf gathering dust, it does no good,” Stirnkorb says.

At her facility, Stirnkorb says, “we practice drills involving disasters at least twice a year.” People learn from practice what to watch out for and where unexpected problems may arise, she says. This past winter, drills turned into “the real thing when we experienced two separate blizzard events.” The imaging department had staff on site throughout the events, and some chose to stay at the medical center during the emergency. “We found sleeping arrangements for them and had food and shower arrangements in place,” Stirnkorb says.

Maintaining Continuity
R.L. “Skip” Kennedy, MSc, CIIP, technical director of imaging informatics for Kaiser Permanente medical centers in Northern California, says health care professionals need to plan not only for disasters but also for business continuity. “I think we focus on disaster planning and recovery and may underestimate business continuity issues,” he says. “It’s not that disaster recovery isn’t important. It is very important. But we put a lot of thought into disaster recovery, and we need to do the same for business continuity,” which is more likely to be an issue on a day-to-day basis.

For example, Kennedy says, his medical centers have a large data center in Northern California and a full disaster recovery system in the Midwest. “If something disastrously hit the Napa data center, we would switch all our systems over to Denver,” he says. “We practice that regularly, and we know that it works.”

But business continuity is more of a concern, he says. “I will have a dozen or more clinical disruption events and have no disaster recovery events in that same time frame,” Kennedy says. For example, Kaiser Permanente’s medical centers have multiple machines that connect to its PACS, “and any one of those machines can cause business disruption. If one goes down, it’s not going to end up triggering a disaster recovery process, but it could be very disruptive to the department where it goes down.”

Kennedy says he needs to have plans in place so that radiology operations can continue if any single point in its system fails. An important exercise, he says, is to “take a really critical look at your workflow and identify all possible single points of failure. If this sends data to that, and that sends data to that, etc, where are the points that a piece of equipment or an application can break that will cause a disruption of the workflow?” This is not an easy exercise, Kennedy says, but it is critical. “Once you identify what could disrupt workflow, then you can figure out a way to make multiple paths through that same problem,” he says. For example, rather than having one DICOM app processing everything, have a dozen.

A Balanced Approach
Other industries, such as banking, seem to be ahead of health care when it comes to backup and recovery, Kennedy says, but health care has begun to adopt two approaches that seem to work well—virtual backup and load balancing.

“Other industries have been doing virtualization for a long time. Imaging has only really gotten into the spirit of it in the last five years,” Kennedy says. “I would say today that most PACS are virtualized. That that makes a big difference for business continuity and for disaster recovery as well.”

Radiology departments have learned that instead of purchasing more servers and managing a data center, it’s better to go to a completely virtual server environment, one that includes a main center and a mirrored system in a disaster recovery location. “It’s changed everything about disaster recovery and business continuity,” Kennedy says. “It makes us much more agile because, rather than having dozens of redundant pieces of hardware, I can have a small number of redundant pieces of hardware and lots of redundant software.”

Such virtualization works well as backup, Kennedy notes, because “computers spend most of their time doing nothing.”

Kennedy says he’d be surprised if all major PACS aren’t doing load balancing these days. “It’s too obvious not to,” he says. Load balancing is a simple way to stay operational should a single application fail. With a load balancing switch, the system can switch to a backup automatically. “It will figure out which one is available and back up automatically.”

Perhaps the biggest threat to health care and imaging systems these days is malware, Kennedy says. “Malware is getting a lot more attention, and things like load balancing and virtualization can help mitigate that. Load balancing and virtualization don’t detract from the need to protect imaging systems from malware, but they can help keep systems operable should malware strike.”

— Beth W. Orenstein of Northampton, Pennsylvania, is a freelance medical writer and regular contributor to Radiology Today.