One year later, Katrina leaves hospitals hurting

Hospitals along the Gulf Coast are still struggling to regain their footing after last year's Hurricane Katrina. The post-Katrina story, culled from interviews with representatives from 23 sites across the affected region, is one of dramatic comebacks by some and a determination to recover and reopen by others. All sites continue to grapple with serious challenges that range from overcrowded facilities to decreased reimbursement and revenues.

Those shortfalls derive from uncompensated storm damages as well as losses from interruption of business. But the biggest fallout from Katrina is a shift in patient mix that has led to soaring numbers of emergency room visits and high demand for imaging services in hospitals that are open for business. Many of the region's stable and insured residents left and did not return, replaced by itinerant or undocumented workers who flocked to the area for reconstruction projects.

While many radiology departments outside New Orleans were seriously inconvenienced by Hurricane Katrina, few sustained major storm damage. Katrina's legacy is the continuing need for hospitals to balance an influx of patients whose treatment choices are limited against the financial liability that the increase in uninsured and indigent patients represents.

Unreimbursed treatment losses are staggering. Among Louisiana hospitals interviewed, indigent care rose from a pre-Katrina range of 2% to 10% to a post-Katrina range of 10% to 30%. At Hancock Medical Center in Bay St. Louis, MS, care for indigent patients has increased from 7% to 22%.

The Ochsner Clinic Foundation, East Jefferson General Hospital in Metairie, and West Jefferson Medical Center in Marrero all remained open during and after the storm and provided treatment to anyone requiring it at a huge financial price. Ochsner sustained a posthurricane operating loss of $59.5 million. In the diagnostic imaging department, exam volume has increased between 5% and 11%, with the exception of nuclear medicine. Much of the increase can be attributed to emergency department patients.1

In Louisiana, the majority of indigent patients receive treatment from an 11-hospital system administered by the Louisiana State University Health Sciences Center (LSUHSC). Charity Hospital and University Hospital, the main teaching facilities for the system in New Orleans, were both badly damaged and forced to close. Although temporary facilities were established, most indigent patients were forced to seek treatment at hospitals outside the state network.

Not only did Louisiana's legislature fail to transfer funds to these private hospitals to help pay for posthurricane uninsured care, legislators cut the budget for these funds by $136 million. In April, the state allocated a portion of the $382 million in relief funds from the federal government to help pay for uninsured care provided through January 2006. But private hospitals expect to see only about one-third of the allocation.

Most hospitals have been operating at a loss, with monthly deficits reaching millions of dollars at some sites.

Touro Infirmary, a multispecialty hospital in New Orleans, wrote off $9 million in bad debts related primarily to uncompensated care in the first six months of 2006, according to Bob Ficken, chief financial officer.

One hospital administrator who requested anonymity summed up the post-Katrina situation that many area hospitals face daily.

"When a person arrives in our emergency department with a horrific construction-related injury who not only doesn't speak English but also doesn't know his address or even the name of his employer, we figure that neither the hospital nor our doctors will see a penny of payment for his care," he said. "But what do you tell that person-to go bleed out on the street? You admit him and treat him."

Such losses affect radiology departments and other specialty services as well as the hospital overall. Many radiologists are working without payment. Others have relocated. While filling staff and technologist positions has not been difficult, attracting radiologists and other specialists has been challenging for some hospitals.

Most facilities are also overcrowded. Dozens of outpatient clinics and seven hospitals in New Orleans are closed indefinitely, although two are operating in temporary facilities. Chalmette Medical Center just outside New Orleans is also closed. Currently, there are only 2000 staffed beds available in a region that once boasted 4400, according to the New Orleans Times-Picayune.2,3 In the city of New Orleans, only 456 staffed beds remain compared with nearly 2300 pre-Katrina.4

Emergency departments are operating at full capacity or greater in most hospitals. At the Ochsner Clinic, emergency visits have risen by 40%. According to a survey by the Agency for Healthcare Research and Quality, approximately 64% of ER visits require diagnostic imaging services.5

"We're seeing a lot more trauma than we used to see. The patients are sicker, too. That makes the jobs of my staff a lot harder," said Richard Stonicher, director of radiology for East Jefferson General Hospital.

Because so many clinics offering mammography screening are closed, procedures have soared at the hospital radiology departments that provide them. Currently, a seven to 10-day backlog exists at Ochsner for diagnostic mammography. This situation is exacerbated by the fact that two of the four Ochsner radiologists who relocated or retired were mammographers.

But hiring replacement staff and technologists has not been difficult: Ochsner fielded 20 applicants for every open job, said Suzanne Young, administrative director of radiology. Some hospitals have added nighthawk services to reduce the round-the-clock high volume demands on radiologists.

East Jefferson Hospital has seen a 25% to 30% increase in emergency department visits, and its imaging volume has risen accordingly. To accommodate MRI patients referred from Tulane University Hospital, it expanded daily operations from 12 hours to 16.

Lakeview Hospital in Covington, LA, has seen MR procedures increase by 28%. But difficulties obtaining radiographic isotopes have reduced nuclear medicine procedures by 51% so far this year.

MR exams have also soared at Leonard J. Chabert Medical Center in Houma, LA. Radiology administrator Jackie Guidry reports a 20% to 30% overall increase, which has required the department to increase full-time technologists from 42 to 55. The images are transmitted to radiologists at Kenner Regional Medical Center.

LSUHSC flagships Charity Hospital and University Hospital were flooded by the levee breaches. Facility damage assessments totaled $258 million and $118 million, respectively. Their neighbor, the VA Medical Center, was similarly affected and relocated operations to Baton Rouge. After the hospitals evacuated their patients, radiology department staffs began an odyssey that had them setting up diagnostic equipment and PACS in nine locations in nine months.

Diagnostic modalities at both Charity and University survived the actual hurricane but were felled by the subsequent flooding and lack of electrical power. At University, disaster teams moved all portable equipment-including mobile imaging devices, PACS workstations, and supplies-from the first floor to the fourth before the elevators stopped working. At Charity, flooding did not affect equipment on the seventh-floor radiology department.

At both sites, flooding destroyed much of the electrical infrastructure. And in the 100 degrees heat, the hospitals' three MR magnets quenched. Nearly a year later, neither hospital has had 220-volt power restored to their radiology departments, so no attempts have been made to check the condition of the devices.

IMAGERS REGROUP, REBUILD

Initially, Charity/University reopened in military MASH tents in parking lots. Radiology services revolved around a portable x-ray unit, an ultrasound device, a large server for image storage, and a diagnostic workstation, all networked together. The conjoined mobile facility then moved into 10 military tents at the New Orleans convention center and leased a mobile CT that was parked outside.

In March, the "Spirit of Charity" moved from the convention center to an emergency treatment facility in an empty downtown department store. Once again, modalities and basic PACS equipment were relocated, and the mobile CT followed.

Level 1 trauma services with 30 beds were added in April at Elmwood Medical Center, a facility leased from Ochsner. Fixed x-ray equipment, additional ultrasound units, and PACS workstations were moved to Elmwood. Three trailers housing CT, MRI, and angiography equipment occupy the parking lot. The PACS is fully operational.

LSUHSC stopped printing images on film five years before Katrina. PACS administrator Scott Lea was not about to return to film during the crisis. Infrastructure and network modifications to the shared PACS have kept it up and running, thanks to Lea and Arthur LaPorte, radiology services director. Because of the PACS, no diagnostic images from the past 10 years were lost, although an estimated 400,000 paper medical records were destroyed.

By January 2007, the Elmwood operation is expected to move into University Hospital, which is undergoing renovation to provide 156 beds. The Department of Veterans Affairs and Louisiana State University are negotiating to build a new, shared VA-LSU medical complex to be completed by November 2011.

At Touro Infirmary, the combination of high heat, humidity, and lack of electricity for an entire month damaged equipment and supplies. The cost to replace modalities is estimated at $6 million. By December, all damaged modalities will be replaced with state-of-the-art equipment and a new integrated PACS. Approximately 60% of the radiologic technologists have relocated, but finding replacements has not been difficult, according to James Hitzman, Jr., director of imaging services. Staffers have been added to every shift for every modality.

Tulane University Hospital was badly flooded. Radiology operations and an undamaged CT unit moved to Lakeside Hospital in Metairie. Even though radiology was located on the second floor, Tulane experienced major equipment loss. Prior to evacuating, department director Sharon Hafner quenched the hospital's MR device. The magnet cracked. The damage was not discovered until the magnet was recharged with cryogen. The MR unit in the sports medicine clinic also quenched and was flooded. An electron-beam CT, nuclear camera for cardiac services, DEXA scanner, and other x-ray equipment located on ground floors were all unrecoverable. Amazingly, the mammography unit survived.

In December, Tulane opened an outpatient urgent care clinic across the street from the hospital with portable x-ray and ultrasound services. Technologists became adept at running across the street to process films. The downtown hospital has since reopened with 63 beds and offers all outpatient imaging services. East Jefferson General Hospital is providing MRI services indefinitely for Tulane's patients. Tulane's airtight film file room was not damaged by heat or humidity. The backup and magneto-optical disks of a miniPACS located at the facility's sports medicine clinic eluded flood waters. Nonetheless, the tapes and MODs all required decontamination.

Nearby Children's Hospital was luckier. Its MRI did not quench, and the radiology department sustained only $200,000 to $300,000 worth of equipment damage. All contrast media, film, and chemicals were thrown away. A new PACS, scheduled for installation in September, finally went live in March.

When Children's reopened in October, its patient volume was only 30% of pre-Katrina levels. None of the radiologists relocated, and most of the technologists stayed. Current patient volumes are just above 80% of last year's levels.

Hancock Medical Center in Bay St. Louis, MS, suffered severe flooding and had to replace nearly all of its modalities at a cost of more than $5 million. A mobile CT trailer supplemented basic radiology services that were initially provided in an emergency services tent. Hancock reopened its hospital emergency department in October. By month's end, 25 inpatient beds were staffed, and surgery began in December. Because of massive loss in population, imaging procedure volume is lower. The hospital has no onsite radiologist, but its PACS enables images to be sent remotely for reading by contract radiologists at a Hattiesburg-based practice.

Other hospitals are relying heavily on PACS. Some say that providing diagnostic imaging interpretation after Katrina's wrath would not have been possible without PACS.

Ms. Keen is a PACS consultant and imaging technology analyst with i.t. Communications of Palm Beach, FL. Her clients include Agfa Healthcare, Acuo Technologies, Eastman Kodak, GE Healthcare, Imaging Dynamics, IDX, Merge e-Film, Philips Medical Systems, Siemens Medical Systems, SmartPACS, Sorna Corporation, and Talk Technology.

References

1. Smith BE. Hospitals in New Orleans see surge in uninsured patients but not public funds. USA Today 2006: 4/26.

2. Shute N. On life-support: New Orleans' against-the-odds struggle to care for the infirm. U.S. News & World Report 2006: 4/24.

3. Berggren R, Curiel, T. After the storm: Healthcare infrastructure in post-Katrina New Orleans. NEJM 2006; 354(15):1549-1552.

4. Freking K. New Orleans' health system still in shambles after Katrina. Associated Press Wire 2006: 3/29.

5. MEPS Statistical Brief #111: Expenses for a Hospital Room Visit, 2003. Jan 2006.