SCRHCFI Best Practices Report Final2 2014 Web

PART 1
Primary Protection: Enhancing Health Care Resilience for a Changing Climate
Primary Protection:
Enhancing Health Care Resilience
for a Changing Climate
U.S. Department of Health and Human Services
December 2014i
PART 1 Primary Protection: Enhancing Health Care Resilience for a Changing Climate
PRIMARY PROTECTION:
ENHANCING HEALTH CARE RESILIENCY
FOR A CHANGING CLIMATE
A Best Practices Document under the HHS Sustainable and
Climate Resilient Health Care Facilities Initiative
AUTHORS ACKNOWLEDGEMENTS
The authors thank the following for their assistance in facilitating the stakeholder
Robin Guenther, FAIA, LEED Fellow
review of this document:
Perkins+Will, Health Care Without
Harm • Critical Infrastructure Protection Program, HHS Office of the Assistant Secretary
for Preparedness and Response
• Health Care Without Harm
John Balbus, MD, MPH
• Forum on Medical and Public Health Preparedness for Catastrophic Events,
National Institute of Environmental
Institute of Medicine
Health Sciences
• Environmental Justice, Labor and Public Health Workshop Review Participants
This document appeared in the Peer Review Agenda for NIH on June 16, 2014. The
authors thank the following peer reviewers for their comments:
• Mark Catlin, Service Employees International Union
• Kim Knowlton, Natural Resources Defense Council
• John Kouletsis, Kaiser Foundation Health Plan
• Hubert Murray, Partners HealthCare
• Jon Utech, Cleveland Clinic
• Jalonne White-Newsome, WE ACT for Environmental Justice
The authors thank the following individuals for their assistance with this document:
• HHS-OASH: Diana Cassar-Uhl, Sarah Field, Sandra Howard
• HHS-ASPR: Steve Curren, Lauren Wolf
• HHS-NIH: Joseph Hughes, Nyron Rouse, Ross Bowling
• Health Care Without Harm: Gary Cohen
The Offices of the Assistant Secretary for Administration and Assistant Secretary for
Health supported this project through contracts with EnDyna, Inc. and MDB, Inc.
Cover Photo Credits:

Top: Ascension’s Our Lady of Lourdes Memorial Hospital in Binghamton, New York. A
flood wall was built in 2011 to keep the hospital operational during times of flooding.
Left: Memorial Sloan Kettering Cancer Center is a leader and early adopter for sustainable
design and climate resilience initiatives. Its 74th St. location is one of the first major health
care facilities to be built in a flood zone post Superstorm Sandy in New York State. It is
targeted to be LEED Silver certified.
Right: Partners HealthCare Spaulding Rehabilitation Hospital is the first building on the
Boston waterfront designed to be climate resilient. The building is LEED Gold certified and
opened in 2013.
iii
Primary Protection: Enhancing Health Care Resilience for a Changing Climate PART 1
TABLE OF CONTENTS
Institution-level Infrastructure: Assessing Hazards and

Part 1: Introduction............................................ 1 Vulnerabilities.......................................................................... 30
Overview.................................................................................... 1 Structural Vulnerability.................................................... 30
Guide and Toolkit Development Process.................................. 1 Non-structural Vulnerability............................................. 30
Purpose and Scope................................................................... 1 Organizational Vulnerabilities.......................................... 31
Key Terms.................................................................................. 2 Transportation and Site Access...................................... 32
Basic Assumptions.................................................................... 2 SPECIAL SECTION: Superstorm Sandy and New York City.... 32
Background............................................................................... 3
Disaster Risk............................................................................. 3
Part 3: Solutions for the Future
Severe Weather, Climate Change, and Health.......................... 4
Infrastructure Solutions for Improved Health Care
Resilience.................................................................................. 5 Climate Resilience........................................... 35
Community Context.................................................................. 6 Overview ................................................................................. 35
Global Context.......................................................................... 7 Resilient Design Principles...................................................... 36
Resilience and Sustainability..................................................... 7 Framework for Climate Resilient Health Care Settings........... 38
Health Care’s Response to Extreme Weather........................... 7 Element 1: Multi-Hazard Assessment: Understanding
Climate Risks and Community Vulnerabilities................. 39
Element 2: Land Use Planning, Building Design, and
Part 2: The Current State of Health Care Regulation....................................................................... 42
Infrastructure Climate Resilience to Extreme Element 3: Infrastructure Protection and Resilience....... 49
Weather Risks................................................... 9 Element 4: Protect Vital Clinical Care Facilities and
Overview.................................................................................... 9 Functions......................................................................... 57
Current State of Health Care Infrastructure Resilience............. 9 Element 5: Environmental Protection and
Strengthening of Ecosystems......................................... 61
Hospital Resilience............................................................ 9
Measuring Resilience: Need and Metrics................................ 65
Research Facilities.......................................................... 10
Embedding Resilience in Infrastructure Decisions.................. 66
Residential Health Care Settings..................................... 11
Investing in Resilience............................................................. 66
Community-Based Ambulatory Facilities........................ 12
Conclusion.............................................................................. 67
Retail and Home Care..................................................... 13
Extreme Weather Risks........................................................... 16
Temperature Extremes: Heat and Cold Waves............... 16 References...................................................... 69
Tropical Cyclones and Hurricanes, Coastal Storms,
and Surge........................................................................ 18
Inland Flooding from Extreme Rain................................. 22 Authors and Acknowledgements.......................80
Tornadoes and Extreme Wind Events............................. 25
Drought............................................................................ 27
Wildfires........................................................................... 27
Landslides, Liquefaction, and Avalanches...................... 29
iv
PART 1: INTRODUCTION
Disasters in hospitals do not have to occur to is resilient to climate impacts. It will also
become the subject of intense planning and collaborate with partner agencies to share GUIDE AND TOOLKIT
programming: future crises and disasters, best practices among federal health facilities” DEVELOPMENT PROCESS
either more or less similar to previous (Executive Office of the President, 2013). The Guide and Toolkit is an initial step in
a collaborative project sponsored by the
occasions, or never-before experienced
These documents have been developed U.S. Department of Health and Human
but anticipated occasions, become part of for sectors and disciplines engaged in Services that will engage a broad group
the imagined reality of hospital staff, are health care facility climate resilience to of public and private stakeholders.
considered as having the potential to occur assist in improving response to extreme
weather events and facilitate a faster
and disrupt the functionality of the hospital,
return to normal or adoption of a new PURPOSE AND SCOPE
and anticipatory planning and corrective normal. Climate resilience, as applied
The goal of the Guide and Toolkit is to
actions take place to respond to them. The to health care, is anchored by the
assist health care providers, design pro-
planning and mitigation that take place are acute care hospital, a “high-reliability
fessionals, policymakers, and others with
organization” that is keenly aware of, and
part of a general culture of mindfulness, a roles and responsibilities in assuring the
sensitive to, broader resilience concerns.
deep-seated awareness that emergencies continuity of quality health and human
Disruptions and losses incurred by the
care before, during and after extreme
and accidents are always lurking under U.S. health care sector after recent
weather events. The Guide is focused on
the appearance of utter normality, so that extreme weather events strongly suggest
health care infrastructure resilience to
that specific guidance on managing the
disasters, either occurring or imagined, are climate change impacts as manifested
new and evolving hazards presented by
used by hospital staff as signals of impending primarily by extreme weather events.
climate change is necessary.
trouble which demand their response Health care, for the purposes of
The Guide and Toolkit is intended this Guide and Toolkit, is defined
(Aguirre, Dynes, Kendra, & Connell, 2005).
to provide key tools and insights to as hospitals, residential health
improve the climate resilience of the care (rehabilitation/long-term care),
full spectrum of health care delivery ambulatory care (dialysis, drug
OVERVIEW settings at the institution (campus or treatment, chemotherapy), retail
The Health Care Climate Resilience facility) level, nested within the broader (pharmacies), and home care settings.
Guide and Toolkit, delivered through the context of regional and community The focus of this resource is institution-
U.S. Climate Resilience Toolkit website infrastructure. This Guide is organized level infrastructure: physical buildings
(toolkit.climate.gov), has been created as in three parts. Part 1 introduces the and campus infrastructure as well as
an initial component of the President’s overall program. Part 2 examines the mobile technologies.
Climate Action Plan. The Plan included characteristics of health care delivery
this recommendation for actions to settings and defines the parameters of Hazard vulnerabilities addressed in the
promote resilience in the health sector: changing extreme weather risks; this Guide and Toolkit include:
part includes case studies of actual • Planning (service locations,
“The Department of Health and Human health care infrastructure responses stormwater, site and transportation
Services will launch an effort to create to historical extreme weather events. access issues)
sustainable and resilient hospitals in the face Part 3 introduces a five-element • Structural (fixed structural elements,
planning framework for improving such as roofs and walls)
of climate change. Through a public-private
health care infrastructure resilience,
partnership with the health care industry, • Nonstructural (utilities,
a framework that in turn guides the
electro-mechanical systems,
it will identify best practices and Toolkit organization. Part 3 highlights
communications systems)
provide guidance on affordable mea- case studies of emergent practices for
improving health care resilience. • Organizational (supply chain and staff
sures to ensure that our medical system accommodation)
1
Not included: Municipal infrastructure/ Critical Infrastructures: Includes connected to vulnerability, and both
Community health infrastructure assets, systems, and networks, both terms are complicated by the lack of a
physical and virtual, that support common metric for assessment (Blanco
Not included: Seismic events/
campuses and buildings, and that are so et al., 2009).
Bioterrorism/ Pandemics
vital their destruction or incapacitation
Not included: Emergency preparedness would disrupt the security, health, Vulnerability: the degree to which a
activities/Evacuation methodologies/ safety, or welfare of the public. Critical system is susceptible to and unable
Regional health care preparedness infrastructure may be manmade (such to cope with the negative effects of
organizing/Regional transportation as structures, energy sources, water, extreme weather or climate change.
transportation, and communication Vulnerability of a building or the built
systems), natural (such as surface or environment is the result of age,
KEY TERMS groundwater resources), or virtual (such condition or integrity, proximity to other
Adaptation: The adjustment of our as information systems) (DHS 2013). infrastructure, and level of service
built environment, infrastructure, and (Ebi, Sussman, & Wilbanks, 2008). The
social systems in response to actual Disaster: an ecological disruption impact of a weather event on a system
or expected climatic events or their causing human, material, or or infrastructure element is mediated by
effects. Adaptation includes responses environmental losses that exceed the its vulnerability.
to reduce harm or capture benefits ability of the affected community to cope
using its own resources, often calling for Vulnerable Populations: Health care
(Intergovernmental Panel on Climate
outside assistance (Centers for Disease professionals define this group as the
Change [IPCC], 2007).
Control and Prevention [CDC], 2014). segments of the general population
Climate Resilience or Climate Change most susceptible to some pathogen,
Resilience: The capacity of an individual, Mitigation: any sustained action disease, or other adverse health
community, or institution to dynamically taken to reduce or eliminate long-term outcome, categorized by age, race,
and effectively respond to shifting climate risk to life and property from hazard gender, income, or other common
impact circumstances while continuing events. This word has two distinct factors. The weather community
to function at an acceptable level. Simply meanings: In the climate change classifies vulnerable groups in terms
put, it is the ability to survive and recover and sustainability context, it means of geographic proximity to discrete
from the effects of climate change. reduction of greenhouse gas emissions weather events or climatic patterns. This
It includes the ability to understand and concentrations; in the disaster document considers both contexts.
potential impacts and to take appropriate preparedness and resilience context, it
action before, during, and after a means any type of risk reduction.
particular consequence to minimize
Resilience: the capacity of a system
BASIC ASSUMPTIONS
negative effects and maintain the ability The following foundational concepts of
to absorb disturbance and reorganize
to respond to changing conditions health care climate resilience are the
while undergoing change to still retain
(Rockefeller Foundation, 2009). basis for this Guide and Toolkit:
function, structure, identity, and the
Critical Facility: Facilities for which capacity for learning and adaptation 1. A network of coordinated health
the effects of even a slight chance of (Resilience Alliance, 2014). care services must remain
disruption would be too great. Critical operational during and following
Risk: the magnitude of an impact and extreme weather events. Acute care
facilities include designated public
the probability of its occurrence. For and emergency medical services
shelters, hospitals, vital data storage
example, the risk posed to a structure must continue uninterrupted.
centers, power generation and water
by sea level rise depends on the rate In addition, essential health
and other utilities, and installations
of sea level rise, the structure’s existing services must remain available
which produce, use, or store hazardous
vulnerabilities, and the rate at which to communities and individuals
materials (FEMA 2014).
the structure can be adapted. Risk is during and immediately following
2
extreme weather events, even vulnerabilities, and community nation ages will place additional stresses
during extended utility outages infrastructure challenges as they on health care infrastructure, continuing
and transportation infrastructure site, construct, and retrofit health to drive significant health care real
disturbances. care facilities. estate development and infrastructure
2. Health care settings continue to 6. Community engagement is a key investments. Continuing local
decentralize from hospitals to a element of health care system development practices to accommodate
range of sub-acute settings such resilience. Communities face unique evolving market demands, such as
as long- term care, assisted living, extreme weather risks and have infilling coastal wetlands and increased
ambulatory facilities, and home varying levels of resilience to those impermeable paving, may also generate
care. Public policymakers and risks. Social factors affect the complex environmental changes and
health care providers must work capacity of communities to prepare contribute to increased risk from
together to determine the minimum for and recover from weather related extreme weather events, if they are not
and recommended infrastructure damage. Because access to health understood and acted upon. Sustainable
requirements for all health care care services is a key element of and resilient development practices
delivery settings. disaster survival and recovery, health are unevenly applied at regional, state
care organizations cannot undertake and local levels, resulting in variable
3. Increasing incidents of extreme
infrastructure resilience without levels of climate change preparedness
weather represent complex hazards
understanding the role of particular in health care infrastructure. There is
that challenge accepted baseline
hospitals, residential care facilities, no acknowledged universal “baseline”
assumptions for infrastructure
ambulatory and home care programs with regard to the ability of health care
capabilities, redundancies,
in the health and wellbeing of infrastructure to withstand impacts of
and disaster preparedness and
community residents, and the social extreme weather events.
response. Climate change is
introducing new threats and new and environmental justice issues that
Finally, health care resilience relies on
building design threshold conditions. define their communities.
more than the viability of its physical
4. Health care organizations play a key facilities. What good is a hospital that
role in community resilience. Health BACKGROUND withstands a 500-year storm if personnel
care workers are first responders; cannot get to work? If supplies of food,
A realistic appraisal of the health care
hospitals are critical facilities. For water, medical supplies or fuel are de-
infrastructure and its vulnerability to
hospitals to remain operational, pleted after 96 hours? As high-reliability
severe weather events recognizes that
both to deliver essential medical organizations, hospitals understand how
weather extremes are and will remain
care and serve as a safe haven for to organize for the unexpected, but sub-
major features of the atmosphere.
residential care settings (such as acute residential settings and ambulatory
Furthermore, forecasts of these
nursing homes) that are adversely care systems have fewer infrastructure
extremes may often be on too short
affected by the weather event, requirements and perhaps less experi-
a time frame to provide enhanced
physical infrastructure (including ence in managing extreme weather risks.
protection to the health care delivery
utilities), key personnel (both Health care preparedness must reflect
enterprise. Climate change and
medical and support), and supply both the increased reliance on these
increasing variability will make future
chain resilience must all be in place. non-hospital settings while acknowl-
efforts to build resilience more difficult,
5. Today, health care facilities are edging their potential increased physical
while extreme weather events are likely
often only as resilient as the vulnerabilities.
to increase health care delivery systems’
communities and regions within exposure to hazards and risk.
which they are located. Resilient
health care organizations must Less obvious is the fact that geographic DISASTER RISK
anticipate extreme weather risks population shifts within the United Risk is a function of the hazard (a
and transcend limitations of regional States and demographic changes as the hurricane, an earthquake, a flood,
public policy, local development
3
or a fire, for example), the exposure Literature emphasizes that a resilient Large-scale weather events in the
of people and assets to the hazard, city, development, or institution is one U.S. pushed total insured claims to
and the conditions of vulnerability of that improves post-disaster through $77 billion. Superstorm Sandy alone
the exposed population or assets. adaptation. No development can expect is estimated to have cost $70 billion
Significant extreme weather risk to completely protect itself or return to with roughly half covered by the private
drivers, according to the United Nations normal after experiencing the effects and national flood insurance programs.
International Strategy for Disaster of severe flood, hurricane, or other Record heat and extremely dry weather
Reduction [UNISDR] (2012) include: disaster; the most resilient communities conditions in the U.S. led to one of
• Growing urban populations and and institutions are able to mitigate the worst droughts in recent decades,
increased density, which put pressure and minimize damage, provide support affecting more than half of the country.
on land and services and emergency services, and take Severe crop failures in the U.S. corn
advantage of the post-disaster situation belt resulted in insured agricultural
• Increasing settlements in coastal
to improve or facilitate positive change losses of $11 billion, the highest ever
lowlands, along unstable slopes and
economically, socially, and ecologically recorded agricultural loss. According to
in hazard-prone areas
(New York City Chapter of the American the IPCC’s Special Report on Managing
• Weak local governance and Institute of Architects, 2013; The City the Risks of Extreme Events and Disasters
insufficient participation by local of New York Strategic Initiative for (2012), the increase in impacts from
stakeholders in planning and urban Rebuilding and Resiliency [SIRR], 2013; extreme weather will remain largely
management UNISDR, 2012). dependent on human activity in terms of
• Inadequate water resource exposure and vulnerabilities.
management, drainage systems, and
According to the American
solid waste management, causing SEVERE WEATHER,
health emergencies, floods and Meteorological Society [AMS] (2010),
landslides
CLIMATE CHANGE, AND the U.S. experiences as much or
• Ecosystem decline as a result of
HEALTH more severe weather than any other
human activities such as road country on Earth. In a typical year,
“Severe weather is a necessary product of
construction, pollution, wetland the nation experiences 10,000 severe
the natural environment. Storms, though thunderstorms; 5,000 floods; 1,000
reclamation, and unsustainable
resource extraction that threatens sometimes powerful and deadly, are nature’s tornadoes; and 10 hurricanes. Extreme
the ability to provide essential temperature and moisture balancing temperatures (both hot and cold) also
services such as flood regulation and have a major effect on vulnerable
mechanisms” (American Meteorological
protection populations—nearly 12,000 people,
Society [AMS], 2010). primarily the aged and economically
• Decaying infrastructure and unsafe
disadvantaged, are hospitalized each
building stocks, which may lead to Globally, the recorded number of
year as a result of extreme temperature
collapsed structures (older building weather-related hazard events that
conditions. Extreme weather events
stocks often contain hazardous adversely affect human populations is
create surges of demand for health care
materials, such as asbestos, in on the rise. Each local and urban context
while simultaneously threatening the
vulnerable locations) is affected differently, depending on the
continuity of that care. The AMS notes
• Adverse effects of climate change prevailing hazards in each location and
that “a changing climate may intensify
that will likely increase or decrease the exposure and vulnerabilities of the
storms that already frequent coasts and
extreme temperatures and region or community. SwissRe (2013),
rip through rural and urban areas on a
precipitation, depending on localized the world’s largest global reinsurer,
seasonal or annual timeframe” (2010).
conditions, with an impact on the reported that 2012 was the third most
frequency, intensity and location expensive year in recorded history for Extreme weather events are associated
of floods and other climate-related natural catastrophes and man-made with a range of health impacts,
disasters disaster losses, costing $186 billion. from immediate injuries and deaths
4
associated with high winds and flooding, and mental health impacts. People “the capacity of a system to absorb
to chronic depression and post-traumatic taking a range of medications, from disturbance and reorganize while
stress disorders seen in weather-related diuretics to anti-psychotics, may be undergoing change so as to still retain
disaster survivors. Temperature extremes especially vulnerable to heat and other essentially the same function, structure,
are associated with increased risks of climate-related stressors. Health care identity and feedbacks” (Walker, Holling,
death and hospitalization from heat systems will need to be aware of these Carpenter, & Kinzig, 2004). Resilience
stress and exacerbation of underlying varied threats that climate-related thinking is a framework applied to
diseases, especially of the heart, kidney, stressors pose to their patients as they social- ecological systems (SESs)
and lungs (Melillo et al., 2014). High assess their specific vulnerabilities. that considers the capacity of social
temperatures and sunlight speed the systems to continue amid either abrupt
reactions that lead to the formation of The Centers for Disease Control and disruption or gradual change. Resilience
the air pollutant ozone, which irritates the Prevention (CDC) have developed thinking examines healthy ecosystems
lungs and causes worsening of diseases robust Climate and Health resources, to understand the factors that increase
like asthma and chronic obstructive including the BRACE Framework – resilience to external challenges and
pulmonary disease as well as increased Building Resilience Against Climate their applicability to social systems.
risk of death. As summer temperatures, Effects – which can assist hospitals and
including the hottest days of summer, public health providers in increasing Architect Thomas Fisher (2013)
become warmer as the result of climate understanding of and developing described our current fracture-critical
change, the peak concentrations of responses to climate-related physical design reality: “centralized infrastructure,
ozone will be higher than they would and mental health stressors. Health including power grids and hospitals,
have been if temperatures had not care organizations and their local public are larger, more complex, dependent
increased, with worsened impacts on health agencies should collaborate upon massive amounts of ongoing
people’s health. Extreme weather events on understanding the likely health maintenance, and may be entirely
may also discourage or prevent patients impacts related to climate change and incapacitated by the failure of a single
on chronic medications from seeking extreme weather challenges for their element.” Unlike in ecosystems,
care or accessing new supplies. Thus, communities. where resilience is assured through
extreme events in a setting of climate redundancy, affluent societies
change may pose the double threat of define efficiency by the elimination
stress to health care systems, including RESILIENCE of redundancy. U.S. health care
the buildings, systems and the personnel infrastructure exemplifies this notion:
“Human societies have never been more operable windows were eliminated once
needed to deliver clinical services, as
well as increased health problems in the globally interconnected and technologically mechanical ventilation came into use;
populations served by those systems. efficient, and less resilient: less able to electrical lighting replaced daylight;
and, ultimately, windows themselves
handle, physically and psychologically, the
In addition to the health threats were perceived as redundant. Now, a
associated with extreme weather events, disruptive changes we will likely face as we loss of backup emergency electrical
climate change is anticipated to pose encounter planetary tipping points in the power renders hospitals completely
threats to human health in a variety decades ahead” (Fisher, 2013). uninhabitable—and the size and
of other ways. According to the Third complexity of backup systems have
National Climate Assessment, threats Ecological economist C.S. Holling increased to the point that they are
to health from climate change include (1973) developed the concept of financially difficult to afford or maintain.
the health impacts of decreased air “resilience” in his study of ecosystem
quality from air pollution, wildfires and health and transformation. Why did The concept of “passive survivability,”
aeroallergens, altered risks of infectious some ecosystems seem unaffected by coined after Hurricane Katrina, suggests
diseases, including waterborne, external human development pressures that buildings should be designed
foodborne, and vectorborne diseases while others collapsed? Through this to survive loss of essential services
like Lyme Disease and West Nile Virus, work, resilience has been defined as such as electricity, water, and sewage
5
management after a natural disaster, of local governments to respond to these hospital emergency departments,
utility outage, or terrorist attack (Wilson, challenges” (2012, p. 7). quickly exceeding the capacity of the
2006) in order to safely accommodate setting to deal with the volume. New
people awaiting evacuation or the Health care delivery systems are also York area hospitals, which typically act
restoration of utility services. For a on the front line of disaster response, as places of refuge for residents from
high-reliability organization’s mission- and must remain operational regardless evacuated nursing homes, were unable
critical systems, such as acute care of the community context and level of to absorb more than 5,000 displaced
hospitals, passive survivability is truly preparedness in order to provide needed elderly residents—particularly for an
the last option—when all systems fail, services to an affected population. extended time following the storm—
passive survivability extends the ability While there is no doubt that regional as many nursing homes sustained
to “survive” within the structure while health networks and independent health significant damage.
an evacuation process is underway. care organizations must participate in
It is imperative to provide multiple and work with regional governments Community resilience is affected by
independent and redundant ways of to develop and maintain sustainable social and economic context. Climate
supplying necessary services and locate risk is not equitably apportioned among
development practices, health care
U.S. communities, while climate-
those services out of harm’s way. organizations must also provide a stand-
related social vulnerability is particularly
alone level of resilience appropriate to
On-site renewable energy, daylight, pota- apparent in communities that experience
the care delivery context and broader
ble water storage and passive ventilation temperature extremes and flooding.
network capacity. For example, health
are examples of strategies that extend Real estate development patterns often
care organizations may not be able to result in economically disadvantaged
the ability to inhabit buildings in the event abandon low-lying coastal communities populations in flood-prone settings.
of major ongoing utility disruptions. Hos- in order to avoid risk from severe storms. Income levels often determine the ability
pitals that incorporate renewable power Because emergency services are es- of community residents to evacuate,
on-site, for example, have a third option sential in disaster events, health care relocate following damage, and return
to operate critical ventilation systems organizations providing critical emer- to repair their homes and businesses. In
when grid infrastructure is unavailable gency response should instead enhance the U.S., a vast majority of low-income
and backup generators fail. their resilience so that they may continue communities of color are concentrated
operations during extreme events. in urban centers in the Southern United
States and along coastal regions–areas
COMMUNITY CONTEXT The physical settings for health care that are at high risk of flooding and
delivery are not limited to the acute major storms and that have a history of
In the handbook How to Make Cities More
care hospital campus. In an era of substandard air quality.
Resilient UNISDR notes:
increasing chronic disease management,
“In disasters, local governments are the first health care organizations operate a “With rising temperatures, human lives–
line of response, sometimes with wide- broad range of care settings. These
particularly in people of color, low-income,
ranging responsibilities but insufficient include residential care settings, such
as rehabilitation, long-term care, and and Indigenous communities–are affected
capacities to deal with them. They are by compromised health, financial burdens,
behavioral health; ambulatory settings
equally on the front line when it comes to that deliver critical, schedule-dependent and social and cultural disruptions. These
anticipating, managing and reducing disaster services to chronically ill patients, such
communities are the first to experience the
risk, setting up or acting on early warning as dialysis centers and substance
abuse clinics; retail settings, such as negative impacts of climate change such as
systems, and establishing specific disaster/ heat-related illness and death, respiratory
pharmacies, urgent care and outpatient
crisis management structures. A review of diagnostic facilities; and an expanding illness, infectious diseases, unaffordable
mandates, responsibilities, and resource range of home care services. In the
rises in energy costs, and extreme natural
allocations is needed to increase the capacity aftermath of Superstorm Sandy, for
example, dialysis patients flooded disasters” (ACJ 2014).
6
In addition to the continuous provision the globe and the larger ecological conditioning for longer periods) or green
of clinical services, hospitals and health and health issues that changing building certification programs, such as
care facilities may play an important weather patterns present affects global Leadership in Energy and Environmental
role in broader community resilience populations. Many of the world’s Design (LEED), many of the solutions
to weather-related and other disasters. major cities are within 100 kilometers improve the inherent resilience of health
Communities may expect hospitals of a coast, and issues related to sea care buildings by reducing dependence
and major health care facilities to level rise affect an estimated 44% on energy and water resources.
provide services, such as access to percent of the earth’s population.
clean water and food, for non-injured International health agencies, including Increasingly, health care workers
or ill community members (Charney, the World Health Organization and the are receiving sustainability and
Rebmann, Esguerra, Lai, & Dalawari, Pan American Health Organization, environmental management training
2013). Such a role may be especially are developing tools and resources through their unions that includes
critical in disadvantaged communities to improve health care resilience to consideration of emergency
where individuals may not have the climate change and extreme weather preparedness and resilience measures.
resources or ability to flee, relocate, or events (see, for example, The SMART Hence, frontline health care workers
access necessary energy, water, and Hospitals Toolkit http://www.paho. are viewing resilience and sustainability
org/disasters/index.php?option=com_ programs as complimentary and
food in a disaster.
content&view=category&layout mutually reinforcing. From environmental
Understanding local community climate =blog&id=1026&Itemid=911). services staff trained in the use of
vulnerability is essential to effective This Guide and Toolkit is intended less-toxic chemicals (which reduces
provision of health services and creates to complement these efforts, as the inventories of hazardous chemicals
unique opportunities for community assessment of risk and resilience that can be exposed to floodwaters)
engagement. Health care organizations measures are relevant worldwide. to security staff briefed on resilience,
and facilities may contribute to disaster worker training is increasingly building
risk reduction and resilience in their on the experience of workers to improve
surrounding communities through the RESILIENCE AND the safety, sustainability, and resilience
following specific actions: SUSTAINABILITY of the health care workplace.
1. participating in community
Many strategies that are employed
partnerships to engage the
to meet sustainable design goals
community in resilience planning
improve resilience. Energy conservation HEALTH CARE’S
2. educating community members on measures, for example, reduce energy RESPONSE TO EXTREME
the challenges that climate presents
and how they can better prepare
demands – a hospital that is less energy WEATHER
intensive can operate longer on a
“And, going forward, good design
3. providing community investments fixed amount of reserve fuel. Medical
and planning should start with the
and health management programs facilities that reduce their water needs
assumption that nothing will work as
that build local social cohesion and can operate longer if they lose water
intended—or even at all. We should, in
improve community health service. Daylit stairwells can be used
other words, take nothing for granted
during daytime hours without need
and act as if we have only those within
for emergency power. Increasingly,
GLOBAL CONTEXT resilience is viewed as the “new
our community and that within our
While this Guide and Toolkit is intended control to depend on … it is the only
sustainable design.”
to address the particular circumstances way to achieve the real optimism of
of U.S. health care, the quest for Whether manifested through stricter knowing that we can survive, and indeed
improved resilience of health care local and national energy codes (which thrive, regardless of what may happen.
infrastructure is a global concern. reduce energy demand and keep We are at our best when we have
Extreme weather is increasing around buildings habitable without heat or air- imagined and accounted for the worst”
(Fisher, 2013).
7
Challenges to the functionality of health to integrate available meteorological made in its built and natural environments is
care delivery are of two broad types: sup- knowledge and engineering solutions at stake. The leaders of our nation, the own-
ply disruptions (the loss or diminution of on a timely basis to protect critical
ers of our critical infrastructure, design and
infrastructure, staff or resources needed infrastructure, most especially hospitals,
for health care organizations to function from known risks. Likewise, it was only construction professionals, and the public as
and deliver care) and demand disruptions following the devastation of Superstorm end-users must take these matters seriously.”
(an increase in patients, actual or antic- Sandy that the Federal Emergency
ipated, in excess of existing capacity). Management Agency (FEMA) expedited For the most part, the science,
The invocation of the disaster plan is a the revision of flood hazard maps along engineering, and emergency
complex outcome of these two process- the northeast Atlantic coast to reflect the management solutions necessary to
es (Haas & Drabek, 1970; Mileti, Drabek, surge effect related to tides and current protect critical health care delivery
& Haas, 1975; Aguirre, Dynes, Kendra, sea level rise conditions. infrastructures and to promote continuity
& Connell, 2005). The AMS (2010) notes of operations already exist. At the same
that “despite the accumulated awareness Tropical Storm Allison, an extreme time, there has been no effective way
of increasing extreme weather events, the rainfall event that resulted in $2 billion to transmit best practices and shared
United States’ critical infrastructure, most in damage to the Texas Medical Center learnings, integrate emergent disaster
specifically hospital infrastructure, re- in Houston, revealed failures to plan infrastructure responses into public
mains unprotected against the expected for weather emergencies or connect policy, integrate the potential increased
movements of our natural environment.” and protect people and resources. risks suggested by climate models, or
In every region of the country, unprece- While the infrastructure was designed critically examine the implications of the
dented extreme weather events—from to withstand flooding, the 30-40 years market shift of health care delivery to
coastal storms to tornadoes, extreme since the previous extreme weather less costly or less resilient settings. The
rain to prolonged drought, forest fires and event depleted institutional memory of AMS (2010) has identified the following
heat waves—have negatively affected flood-proofing measures. Both Hurricane as barriers to improvement:
the full range of health care delivery in all Katrina and Superstorm Sandy • a general lack of awareness of
types of settings. highlighted not only the vulnerability environmental vulnerabilities on the
of hospital infrastructure, but the part of local decision makers
Five past events—Superstorm Sandy disruptions to the broader continuum of • an absence of coordination and com-
(2012), Cumberland River floods (2010), health care services that take place in far munication across federal agencies
Mississippi River floods (2008), Hurricane less resilient and prepared but equally • a paucity of financial resources or
Katrina (2005), and Tropical Storm important residential, commercial, and incentives to encourage needed
Allison (2001)—highlight the fragility retail settings like nursing homes, mental structural mitigation or adaptation for
and vulnerability of America’s health health and drug treatment facilities. current and projected weather risks
care infrastructure to severe weather.
Hurricane Katrina, an event that captured Infrastructure responses to the challenges Despite progress in some regions of
global attention, displayed with stunning of extreme weather have been developing the US, challenges remain with health
clarity the vulnerability of New Orleans for at least a decade. The American care infrastructure resilience. While the
to hurricanes, despite concerns that Society of Civil Engineers (2009) noted weather itself and its direct effect on the
had been raised following each major that the U.S. is beginning to acknowledge health care system are uncontrollable,
storm and more significant evacuations: the fact that its aging infrastructure is in some elements of the system’s
Hurricane Juan (1985), Hurricane Andrew need of repair, a situation exacerbated vulnerability can readily be improved. The
(1992), and Hurricane George (1998). by the dynamic conditions of shifting difficulty lies in sharing and coordinating
Katrina also triggered tremendous extreme weather patterns: the information. This Guide and Toolkit
disruptions that overwhelmed health are intended to bring together available
“Public safety, health, and welfare are at
care delivery facilities in and around tools and resources to help policymakers
stake. The nation’s economic well-being is and institution-level decision makers
New Orleans and the Gulf Coast. In
many ways, Katrina epitomized a failure at stake. The investment that the nation has improve health care resilience.
8
PART 2: THE CURRENT STATE OF HEALTH CARE

INFRASTRUCTURE CLIMATE RESILIENCE TO
EXTREME WEATHER RISKS
• Increasing capabilities for “islanding Once established, they rarely moved.
OVERVIEW operation” that recognizes that on- To this day, a large number of hospitals
Every state in the U.S. experiences ex- site infrastructure, staff, and supplies occupy waterfront sites in cities and
treme weather. This section begins with an may be required for extended periods towns across the country.
examination of the current state of resil- of time following weather events
because of damaged community Hospitals are licensed by the states
ience in each level of health care delivery,
infrastructure (regional electrical grid, in which they operate. The Facility
followed by specific discussion of each
municipal potable water supplies, Guidelines Institute’s (FGI) Minimum
extreme weather risk, associated climate
roads and transportation networks, Standards for the Design and
impacts, and case studies of health care’s
communication systems) and that Construction of Hospitals and Health
response to each category of event.
facilities may need to operate for Care Facilities (Facility Guidelines
more than 96 hours without aid from Institute, 2014), an outgrowth of U.S.
the community Department of Health and Human
CURRENT STATE Services standards for the construction
OF HEALTH CARE Hospital Resilience of hospitals under the post-WWII
INFRASTRUCTURE The focus of resilience in health care Hill Burton Act, designate minimum
fuel supplies, and define mechanical,
RESILIENCE facilities has been historically centered
electrical and communication systems
on acute care hospitals. Because of the
Climate change contributes to the that must be supplied by on-site
compromised health of inpatients and the
increase in the incidence of extreme emergency power systems. The FGI
complexity of evacuation and transport,
weather across the U.S. For health care Guidelines reference a series of National
hospitals are designed and constructed to
infrastructure to be resilient in the face of Fire Protection Association (NFPA)
“shelter in place” during and after sentinel
extreme weather, adaptation measures and National Electrical Code (NEC)
events, including extreme weather.
are required. Adaptation measures that standards that must be compared to
In general, they rely upon emergency
respond to climate change impacts can local requirements; the more stringent
electrical generators (fueled by diesel
be categorized in the following ways: is applied. The FGI Guidelines have
oil) to provide required electrical power
• Increasing design thresholds to if the municipal grid, or their internal been adopted by 38 state legislatures,
recognize more severe weather normal electrical system, fails. Generally, and considered informally by 4 others.
intensities (design thresholds include thermal energy is provided by on-site They are periodically updated using a
design temperatures, wind velocities, boiler and chiller systems (also known as consensus process.
mean flood elevations) central utility plants, or CUPs), which, if
In addition to these minimum
• Increasing warehousing and storage undamaged and given uninterrupted fuel
requirements for facilities, hospitals
capacities to recognize more severe supply (natural gas) or sufficient on-site
comply with state and local zoning
weather durations (increasing the fuel storage (most commonly oil), can
and building code requirements.
minimum amounts of on-site food, remain operational through municipal
These codes, collectively, define a
water, and fuel storage) electrical grid disruptions.
“minimum” standard of construction.
• Enacting requirements for hardening The Joint Commission (TJC) accredits
facilities in new geographic regions to According to the U.S. Energy
Information Agency, the average hospitals, but does not set resilience
respond to changing extreme weather criteria. In some instances, the Centers
frequencies and patterns (adopting age of a U.S. acute care hospital is
approximately 31 years (USEIA 2006); for Medicare and Medicaid Services
requirements for exterior building (CMS) also require specific compliance
envelope or electro-mechanical most are multi-building campuses that
include buildings built from as early with NFPA or NEC standards in order
system resilience in geographic to qualify to serve Medicare and
regions that have historically not as 1910 through contemporary time.
Historically, hospitals sought land near Medicaid populations. The Veterans
required such measures but may be Administration has its own set of design
vulnerable in the future) bodies of water—rivers or the coast—for
water supply and sewage discharge. criteria. One of the confusing elements
9
of multiple authorities is the lack of FEMA maps (extreme weather ·· Reliance on on-site diesel
alignment between the editions of cited events exceed thresholds with emergency generator plants,
reference standards. Whether facility catastrophic results) which have grown larger and
design must meet the NFPA 2000 ·· Reliance upon aging municipal more complex, require ongoing
edition, 2004 edition, or 2012 edition flood protection infrastructure that maintenance and testing, and are
may not be clear, which can result in fails, such as the levees in New prone to failure under full load
wide variations in facility standards as Orleans or Mississippi River dikes conditions (required fuel storage
they relate to climate resilience. may be too short to allow for safe
·· Reliance upon municipal thermal
refueling in a weather emergency,
According to The Joint Commission energy infrastructure (such as
when fuel shortages are acute and
(TJC) (Fink, 2012), new hospitals in some district steam) that fails or must be
roads may be impassable)
U.S. coastal low-lying areas are not pre-emptively shut down
required to flood-proof their systems; • Regulatory Conflicts Following extreme events that include
the level of resilience is dependent ·· Contradictory regulations, codes hospital evacuations, local regulations
upon local regulation. The result is and utility practices, which often shift to redefine minimum flood
hospitals that may be compliant, but require diesel fuel storage and elevations and revise requirements for
remain unprepared. TJC and CMS locate major utility infrastructure critical infrastructure placement. How-
require hospitals to adhere to the 2000 such as electrical switchgear at ever, the wide variation in established
edition of the National Fire Protection grades vulnerable to flooding practices leads to limited cross-industry
Association’s life safety code. It calls (these contradictions can be at sharing of lessons learned. Regional
for “careful consideration” to protecting an infrastructure system level or, differences between extreme weather
electrical components from “natural in major cities, at a zoning level, event types and limited understanding of
forces common to the area” such where limitations on above grade future hazard risks further contribute to
as storms, floods and earthquakes bulk and floor area leads to below inconsistency of best practices.
(National Fire Protection Association, grade infrastructure placement)
2000). The 2012 version of the NFPA Research Facilities
• Building envelope failures
code strengthens its language, saying
·· Building façade and enclosure While much of the focus on hospital
the systems “shall be designed” to
failures, along with improperly evacuations is on the direct impact to
protect against these hazards, but
anchored equipment in high inpatients, there are significant impacts
leaves the assessment of minimum
winds, resulting in equipment to research and medical education
requirements for such protection to
blowing off roofs, which functions that can be as or more costly
state and local jurisdiction, which results
compromises roofing systems and and disruptive. Often underreported,
in varying requirements throughout
waterproofing flooded below-grade vivaria result in
the U.S. The conclusion, according to
·· Envelope failures related to the the loss of years of scientific research
George Mills, director of the Engineering
age or condition of building samples; power lost to research freezers
Department at The Joint Commission,
enclosures that were designed and refrigerators ruin years of grant-
is that “all of these systems are only as
prior to contemporary extreme funded research. The cost of a tertiary
reliable as the weakest link” (Fink, 2012).
weather considerations or building academic medical center’s evacuation
The inability of hospitals to function code regulations and shutdown amounts to more than
through extreme weather events in the the inconvenience, relocation, and repair
• Building infrastructure systems failures
last two decades can be traced to one costs; it can alter medical research
·· Aged and complex critical progress. Hurricane Katrina forced the
or more of the following issues:
infrastructure in multi-building Tulane Medical School to relocate to
• External infrastructure dependence
campuses, making hospitals Houston for a year. Research losses
·· Reliance upon, and compliance highly vulnerable to “fracture- at NYU Langone Medical Center have
with, the minimum flood elevations critical” failures (see Part 1) given the National Institutes of Health
designated by local zoning and
10
(NIH) reason to consider weather residential providers must look after the the public mind about the ability of facilities
vulnerability in grant funding. The Texas health, safety, and well-being of these that care for the elderly to make the best
Medical Center story, profiled on page vulnerable populations.
decisions when a disaster occurs or is
64 of this guide, demonstrates the
urgency for patient care, teaching, and Until recently, there was little focus on imminent” (2013, p. 43).
research facilities to implement more Residential Care facilities in the FGI
Guidelines. There are limited specific After Hurricane Katrina in 2005,
sophisticated, resilient responses to
requirements for emergency power most nursing home administrators
the infrastructure challenges posed by
systems in residential health care became familiar with FEMA’s 2008
climate-induced extreme weather events.
settings. Residential care facilities National Response Framework for
have staff training for “shelter in place” communitywide emergency planning,
Residential Health Care Settings mechanisms during emergencies. They and with federal emergency support
As health care delivery moves out are required to meet local zoning and functions. They revised their disaster
from the acute care hospital setting, building codes; however, the number plans to incorporate a nursing home-
the resilience of the facility to extreme of states enacting the FGI Guidelines specific incident command structure.
weather measurably decreases. Over the provisions for long-term care facilities is The Emergency Management Guide for
last 50 years, the expansion of residential far fewer than those enacting hospital Nursing Homes provides an example
care facilities has been significant, with provisions (13 use nursing home (see Resources). The National Response
concentrations of long-term care and requirements, 11 enforce the guidelines Framework was expanded and updated
assisted living facilities in more vulnerable for assisted living facilities, and 13 in 2013 (FEMA, 2013).
coastal areas (particularly along the consider the guidelines in hospice care
Research suggests that nursing home
Atlantic and Gulf Coast regions). Included settings (FGI, 2014)). Hence, there is
residents that shelter in place have
in this category are nursing homes, which limited consistency among minimum
better health outcomes than those that
offer skilled nursing for the elderly and standards for construction. Local
are evacuated or transferred during
very frail in need of ongoing medical hospitals and spare capacity in the
or following an event. During the four
attention, and adult care facilities, which regional systems act as safe havens
hurricanes in Louisiana and Texas
primarily support residents who require when nursing home or rehabilitation
(Katrina, Rita, Gustav, and Ike) residents
help with basic daily tasks such as meals facilities are forced to close.
who were evacuated from nursing homes
or bathing. Other residential facilities offer
Kathryn Hyer, PhD, MPP, Director, Florida had higher post-storm death rates and
treatment, care, and supportive housing
Policy Exchange Center on Aging, hospitalizations compared with residents
for individuals with substance abuse
University of South Florida, and an expert in facilities that sheltered in place. The
problems, developmental disabilities,
on nursing home evacuations, notes: conservative estimate is that 94 “excess”
or other behavioral or mental health
deaths were due to evacuations resulting
challenges. “Recent events have shown that disaster- from those four storms (Hyer, 2013).
These facilities have complex ownership, related outcomes for this population, even Hence, ensuring that nursing home
governance, and financial structures, when they survive the immediate danger, facilities have structural and system
ranging from licensed long-term care often are especially poor. Further, post- integrity and have the resources to
facilities owned and managed by self-sustain for a period during an
disaster studies have shown that facilities
non-profit integrated health networks event is certainly a best practice.
that care for the elderly, particularly those Another is making sure that supplies,
to small, individual, private for-profit
endeavors that operate “below the that are for-profit or privately owned, often personnel and fuel can be replenished
radar” of licensure and regulatory have been excluded from or overlooked during the aftermath, before systems
requirements. Physically, they range in community emergency planning … return to normal. Depending upon the
from large, institutional campuses severity of the event, an inability to
Recurring controversies in the news over the
to adapted single-family homes. sustain operations during recovery may
past decade have raised serious questions in compromise resident safety.
Regardless of the size of the facility, all
11
In a major regional weather event, such • Vulnerability of building envelope, the unpredictable storm conditions
as Hurricane Katrina or Superstorm elevator machinery, stair towers, and increased the risk that any New Yorker could
Sandy, the widespread destruction of interiors to severe damage from wind
residential care venues created a care require life-saving medical care” (The City of
projectiles and/or water
dilemma that far outlived the actual New York, 2013, p. 145).
• Lack, insufficiency, or failure of
event. This dilemma was captured by
emergency power and, consequently, Like residential facilities, communi-
the New York City Strategic Initiative on
the loss of elevator service and water ty-based ambulatory facilities vary widely
Resilience and Reconstruction (SIRR)
supply to upper floors in terms of ownership, licensure and
report following Sandy: nursing home
patients (coupled with the hospital governance. They are built to varying
Community-Based Ambulatory
transfers from impacted acute care physical standards. Facilities with more
facilities) filled all available hospital Facilities than four patients incapable of self-pres-
beds and overwhelmed emergency Community-Based Ambulatory ervation (such as an ambulatory surgery
departments for weeks and months Facilities include large community center) in states that require the use
following the event (The City of New clinics that provide primary care, of FGI Guidelines must meet require-
York, 2013) (see special section on mental and behavioral health services, ments for enhanced life safety systems
Superstorm Sandy beginning on page and other outpatient services to the and emergency power. Physician office
32). Following Katrina, nursing home general population every week. Other practices, cancer treatment centers, and
residents were dispersed hundreds of community-based providers include the vast majority of ambulatory facilities
miles from New Orleans, losing contact private doctors’ practices for urgent, with fewer than four patients incapable of
with consistent medical care as well primary and specialty care, dialysis self-preservation are considered “busi-
as family support. Similar experiences centers, hospital-affiliated outpatient ness occupancies.” Many are located
following Hurricane Andrew in 1992 led
providers (such as ambulatory surgery in rental spaces, either in commercial
the state of Florida to adopt strict new
and cancer treatment), independent ground floors or as tenants in multi-
building codes (see pullout).
clinics, and retail pharmacies. The SIRR tenant office/commercial buildings.
The Post-Sandy Initiative reported report noted these larger stressors on Hence, when the commercial building
that, “In Brooklyn and Queens, 29 the ambulatory health care delivery loses power, all tenants are affected. Fail-
nursing homes were severely damaged; system following Sandy: ures of ambulatory facilities may result
despite receiving instructions to shelter “Flooding and power outages forced from the following:
their populations in place, they were • Reliance upon the minimum flood
community clinics, doctors’ offices,
unprepared to endure the storm and its elevations designated by local zoning
pharmacies, and other outpatient facilities and FEMA maps (when weather
desolating aftermath” (New York City
Chapter of the American Institute of to close or reduce services in the areas events exceed these thresholds, the
Architects, 2013). The following factors most impacted by the storm. Sandy not effects on envelope and infrastructure
contributed to the failure of residential are catastrophic)
only put unprecedented stress on the
long-term care and rehabilitation • Reliance upon municipal flood
provider system; it placed the health of
facilities to shelter in place effectively: protection infrastructure that fails,
• Reliance upon, and compliance medically fragile individuals at risk. There such as the levees in New Orleans
with, the minimum flood elevations were an estimated 75,000 people in poor • Vulnerability of building enclosure,
designated by local zoning and FEMA health living in areas that were inundated infrastructure systems and/or
maps (weather events can exceed interiors to severe damage from wind,
by floodwaters and an estimated 54,000
thresholds with catastrophic results projectiles and/or water
for envelope and Infrastructure) more in communities that lost power. These
• Reliance on municipal electrical grids
• Reliance upon municipal flood groups faced additional health risks during
with inadequate emergency power
protection infrastructure that fails, the storm and were less capable of gaining provisions in the case of grid failure
such as the levees in New Orleans access to appropriate care …. Furthermore, • Disruption of transportation
12
infrastructure and gasoline shortages, post-event” (Evans and Carlson 2012). care providers. Extreme weather can
limiting the ability of staff and patients This notion of advance preparation for a be challenging for continuity of care
to access the facilities different, potentially expanded health care as this excerpt from the SIRR report
patient surge profile post-event is a key summarizes:
In extreme weather events, particular element of hospital resilience planning. “Home-based care was impacted primarily
specialty care providers, including Understanding the network vulnerabilities
dialysis units, mental health and drug/ by disruptions in the transportation system.
before extreme weather events can lead
alcohol treatment centers, face unique to enhanced resilience recommendations The public transportation shutdown, travel
challenges if forced to close. These for key ambulatory services. restrictions on single-occupancy cars, and
patients require consistent, frequent
gasoline shortages all made it difficult for
long-term outpatient care. When The SIRR report notes that, in New York,
patients are forced to shift providers,
nurses and aides to reach the homes of
more than 10% of ambulatory capacity
gaps in treatment plans occur. The SIRR resides within the 100-year flood zone patients scattered across the five boroughs.
report notes that patients: in newly-released 2014 FEMA Flood If and when providers finally did reach
“with pressing health care needs—dialysis Insurance Rate Maps. In coastal areas, their destinations, elevators that were out
there remain possibilities for significant
patients or those on methadone, for of service—due to power outages or flood
disruption of the ambulatory care
instance—had to seek alternative care network in extreme weather events. As a damage— often made it challenging for
immediately, often from hospital emergency result, New York City recommendations staff to reach patients on upper floors in
departments or mobile medical vans staffed include equipping a portion of high-rise buildings. The power, water, and
ambulatory health facilities in 100- and heat outages within patients’ homes were
by doctors and nurses from community
500-year floodplains with emergency
clinics and other health care workers. also problematic, increasing the likelihood
power provisions and external generator
hookups (The City of New York, 2013). that existing medical conditions would
The longer providers remained closed, the
worsen or new ones would develop” (The
greater the numbers of individuals who had
In addition to disrupting mental health City of New York, 2013, p. 149)
to look elsewhere for care” (The City of New service delivery, extreme weather
York, 2013, p. 149). events can also increase the need for Informal, unstructured aggregations of
mental health services, as impacted vulnerable populations are also increas-
After being closed by a disaster, communities cope with the stressors ingly common. These Naturally Occur-
community-based providers generally inherent in loss of individual life, ring Retirement Communities (NORC’s)
have a seven day window to resume livelihoods or possessions as well as loss often form in coastal communities or in
care before emergency departments and of community cohesion (Shukla, 2013). small cities across the U.S. For example
hospitals are affected by their absence. apartment buildings that have a cohort of
Jersey Shore University Medical Center residents that have aged in place can be-
Retail and Home Care
in Neptune, N.J. remained functional come, in essence, a retirement commu-
during and after Superstorm Sandy, Health care and health care support
nity (Masotti, Fick and MacLeod, 2006).
but was near some of the hardest-hit services are delivered through an
These multi-family residential buildings
communities. Steven Littleson, president, extensive network of retail providers,
have no primary resilience characteris-
observed: “The biggest challenge is ranging from urgent care centers to
tics, such as elevators on emergency
making up for the other services that are dialysis centers to retail pharmacies.
power, and are vulnerable to primary
not available in the community.” Littleson Major pharmacy retailers are able to
grid and water supply interruptions. The
admitted the hospital had not prepared provide mobile services once roads
population is less able to use stairs to
to become the region’s major primary- reopen. In addition, many hospice
carry water and food home over extend-
care and social-services provider. “If patients and homebound elderly patients
ed blackouts, or to effectively clean when
there is a lesson here, it is to gear up for with chronic diseases are cared for
services are restored.
a broader array of primary-care services, at home through a network of home
13
The State of Florida’s Path to Increased Health Care Resilience

In 1992, Hurricane Andrew made landfall 20 miles south of the apex of the Miami business district. In addition to the staggering human cost, the
valuation of destroyed property was, until that time, the largest in United States history. Homestead Hospital, severely damaged by the storm,
was partially reopened within seven days of the event. In 2007, it was completely replaced by a state-of-the-art facility designed to withstand
stronger storms, but not before the loss of more than 50 percent of its staff, who left the storm-ravaged region following the event. Even after
21 years, the town of Homestead, Florida has not fully recovered from the storm. Despite being the sole community hospital in the region, the
hospital continues to face operational losses due to a changed community.
Hurricane Andrew’s impacts on health care facility infrastructure led Florida to completely reconsider preparedness and resilience, including
development of a robust integrated statewide emergency management program. A series of policy documents, most notably the 1993 Lewis
Report, recommended that the state enact a series of building codes that would ensure that hospitals, nursing homes, and intermediate care
facilities for the developmentally disabled be constructed to withstand storm damage and be self-supporting during and immediately following
coastal hurricane events. The Agency for Health Care Administration (AHCA) developed a series of regulations requiring wind and impact-
resistant building envelopes, equipment-anchoring systems, and emergency generators above surge levels for all new facilities constructed
over the last 20 years. In addition to on-site emergency generators, facilities are required to have external connections for portable generators
that can provide operational power to the entire facility. The state prohibits new hospital construction in the 100-year hurricane surge
inundation zone; it requires all health care projects to adhere to the SLOSH (Sea, Lake, and Overland Surges from Hurricanes) modeling for
Category 3 (Saffir-Simpson scale) storms and to set elevations for floors and patient/resident support infrastructure equipment based upon the
results. These requirements notably improve performance. See Case Study of Tampa General, on page 58 of this guide.
With regard to retrofitting, the situation has remained complex due to concerns about the cost of proactive requirements for hardening,
particularly in the vast inventory of existing hospitals and nursing homes. For facilities damaged by storms, all replacement systems were
required to meet the newly enacted codes. For ongoing general retrofits, there was no similar requirement until 2004, when the Florida Building
Code was revised to require all ongoing renovations, such as window replacements and generator replacements, to comply with current
standards for facility hardening. This carefully-worded mandate has accelerated improvements in existing buildings. A comprehensive set of
guidelines for coastal storm nursing home retrofits is included in their 1999 Recommended Physical Plant Improvements to Existing Nursing
Homes for Disaster Preparedness (S. Gregory, personal communication, January 20, 2014).
14
CASE STUDY: Miami Children’s Hospital, Miami, Florida

The 268-bed Miami Children’s Hospital (MCH) serves seven counties in southern Florida, including populous Miami-Dade County, and is the
region’s only specialty hospital for children. Beginning in 2001, MCH underwent a state-of-the-art retrofit to enable it to withstand a Category 4
hurricane. It is now wrapped in a hurricane resistant shell.
Following implementation of more stringent building codes in the 1990s, an assessment of the mid-1980s facility’s exterior construction
revealed that it was unsafe when wind speeds reached those typically associated with a Category 2 hurricane, a common occurrence in
southern Florida. Since many of the special pediatric services provided at MCH are not available in other area hospitals, a hurricane event would
have been detrimental to children in need of specialized medical care if evacuations had to take place or if the facility was closed during repair
after a storm.
Hospital administrators had to solve a two-fold problem: how to fund the renovation project, and
how to execute the retrofit and renovations without disrupting medical services. The hospital
received funding through FEMA’s Hazard Mitigation Grant Program (HMGP), administered by the
Florida Department of Community Affairs (DCA). A $5 million HMGP grant was awarded by the
State of Florida to help pay for the $11.3 million project. The retrofit strengthened the building
by encapsulating the three-story structure in pre-molded panels of glass fiber reinforced
concrete (GFRC). The panel system, anchored into the building’s existing support structure,
forms a protective cocoon around the hospital and, along with impact-resistant windows and
a strengthened roof, enables the building to withstand winds of up to 200 miles per hour.
The architect’s approach of working from the outside to the inside of the building made it
possible for surgeries, diagnoses, and nursing care for the hospital’s young patients to continue
uninterrupted throughout all phases of the renovation.
The project was completed in the spring of 2004, just prior to Florida’s hurricane season. Young Figure 1: Miami Children’s Hospital
patients and their families did not need to evacuate from the hospital when Hurricanes Frances retrofitted its façade to withstand
and Jeanne struck. In addition, the hospital welcomed over 60 children who lived at home hurricane force winds.
but were evacuated from the Florida Keys—children who depended on ventilators or other
electrically-powered medical equipment.
During Hurricane Frances, MCH was the temporary refuge for nearly 1,000 staff members and their families. According to Kevin Hammeran,
Senior Vice President and Chief Operating Officer during this period:
“The strengthened building has enhanced the hospital administration’s ability to recruit staff to serve during hurricanes. Many employees
feel safer at the hospital during a storm than in their own homes. We also have eliminated barriers by providing on-campus shelter for family
members of storm-duty staff. Knowing their spouses and children are within the safe confines of the hospital gives peace of mind to those
working through the storm.”
In 2005, the hospital hosted medical evacuees and families who were displaced by Hurricanes Katrina and Wilma.
(Source: U.S. Department of Homeland Security, 2014)
15
that over the last several decades heat Most heat injuries that occur during a
EXTREME WEATHER waves are generally increasing, while heat wave are caused by overexposure
RISKS cold waves are decreasing (Peterson to heat or activity that is too strenuous
et al., 2013). At the same time, recent given the weather and the person’s age
Given the current state of health care
“polar vortex” cold events in the and physical condition. Older adults,
infrastructure resilience, how are
central and southern U.S. are proving young children and those who are
future extreme weather events likely to
challenging to infrastructure and health sick or overweight are more likely to
affect health care delivery in the U.S.?
care services. succumb to extreme heat. Also, asphalt
This section examines different types
and concrete store heat longer than
of extreme weather events, reviews A heat wave is an extended period of natural surfaces and gradually release
projections about the frequency and extreme heat, and is often accompanied heat at night, which can produce higher
intensity of these events, and discusses by high or low humidity extremes. The nighttime temperatures. This is known as
the current state of the U.S. health care National Oceanic and Atmospheric the urban heat island effect. Residents
infrastructure’s resilience to these events. Administration (NOAA) summarizes the of economically disadvantaged
unique aspects of heat waves: communities are less likely to have
This document focuses on the effect of
climate change and increased climate “Extreme heat may be one of the most air conditioning in their housing or
variability on health care systems and the ability to pay for it. Consequently,
underrated and least understood of the
infrastructure. As noted previously, people living in large urban areas may
deadly weather phenomena. In contrast to be at greater risk from the effects of a
climate change affects the health of
the visible, destructive, and violent nature prolonged heat wave than those living in
populations in a variety of ways, and
health care systems need to be aware associated with ‘deadly weather,’ like floods, rural areas. In sealed buildings (buildings
of these impacts in allocating resources without operable windows), loss of
hurricanes, and tornadoes, a heat wave is
and planning for services. A full mechanical cooling (air conditioning)
a ‘silent disaster.’ Unlike violent weather during heat waves can produce a rapid
description of these impacts, however,
events that cause extensive physical rise in interior temperatures, rendering
is beyond the scope of this document.
The reader is referred to the Third destruction and whose victims are easily spaces uninhabitable.
National Climate assessment [Melillo et discernible, the hazards of extreme heat are According to the CDC, 660 people die
al., 2014] and relevant federal websites dramatically less apparent, especially at the nationwide from heat waves each year,
http://www.cdc.gov/climateandhealth/
onset” (NOAA, 1995, p. viii) making it the leading cause of weather-
publications.htm, http://www.niehs.nih.gov/
related mortality in the country. Studies
research/programs/geh/climatechange/ There has been a remarkable run of suggest that, if current emissions hold
health_impacts/index.cfm, and http:// record-shattering heat waves in recent steady, excess heat-related deaths in
www.globalchange.gov/what-we-do/link- years. The Russian heat wave of 2010 the U.S. could climb from the current
climate-health] for further information. that set forests ablaze, the historic average of about 700 each year to
heat wave in Texas in 2011, and the between 3,000 and 5,000 per year by
Temperature Extremes: Heat and “Summer in March” in the U.S. Midwest 2050 (U.S. CDC 2013).
Cold Waves in 2012 are all memorable heat waves.
The 2003 heat wave in France claimed During heat waves, health care service
Heat and cold waves are typically
14,802 lives. Across the contiguous volumes surge as residents in the area
defined as events exceeding specified
United States, new record high present to emergency departments,
temperature thresholds over a minimum
temperatures in the past decade have urgent care centers, and physician
number of days. Thresholds are often
outnumbered new record lows by a ratio practices. At the same time, the urban
geographically specific – the significance
of 2:1. There are a number of models energy infrastructure is over-stressed;
of night temperatures greater than 80
that suggest there will be an increase the electrical grid is challenged to
degrees F is more significant in Chicago
of heat waves and seasonal shift for the provide sufficient energy to meet
than it is in Houston. The data indicate
U.S. in the coming decades. residential and commercial cooling
16
demands. As a result, rolling electrical operable windows (and engineered decades, they still occur and can have
blackouts often accompany extended natural ventilation systems) are a key significant impact (Peterson et al., 2013).
heat waves, which can compromise element of passive survivability during
health care delivery. Urban hospitals, as extended heat waves in non-acute A cold wave can cause poorly insulated
large electricity consumers, are often residential health care settings in many water supply pipes and mains to freeze.
asked to shift to emergency power parts of the United States. Ambulatory It may impact building water supply
generation in order to free grid resources facilities vary widely in their emergency piping, if not buried deeply enough
during peak demand periods. power provisions and capabilities. underground. In addition, regions of
the U.S. that experience limited cold
Many hospitals do not have their cooling The National Weather Service defines a weather have come to rely on electric
systems on their emergency power cold wave (or, in some regions, a cold heating for residential buildings; hence,
generation systems; when blackouts snap) as a phenomenon distinguished when temperatures plunge, electrical
occur, hospitals are required to continue by a rapid fall in temperature within a demand peaks or exceeds grid
to operate their basic ventilation 24 hour period. The criterion depends capacity, resulting in rolling blackouts.
systems but may lose portions of their on the rate at which the temperature In addition, cold waves accompanied by
space cooling systems. For the most falls and the minimum to which it falls, precipitation often produce ice storms,
part, hospitals are sealed buildings; as well as the geographic region of the resulting in massive transportation
i.e., they do not incorporate operable country where it occurs. Extreme winter disruptions, electrical grid interruptions,
windows due to infection control and cold is often devastating to agriculture and increased emergency service
pressurization requirements. In recent and livestock. Cold waves affect much activities as auto accidents and slip-
years (and, in particular, following larger geographic areas than blizzards, and-fall injuries peak. Like heat waves,
the extended 2006 blackout in the ice storms, and other winter hazards. cold waves have greater effects on the
northeastern U.S.), many hospitals While the frequency of cold waves has poor and elderly, as these populations
have improved their resilience to heat been decreasing over the past few are less likely to have the financial
waves by voluntarily increasing their
emergency power capability above
minimum regulatory requirements to CASE STUDY: University of South Alabama Medical
include mechanical cooling. In Florida,
hospitals are required to have an
Center, Mobile, Alabama
external generator connection that Amid a heat wave in August 2010, University of South Alabama Medical Center lost both its
allows additional generator capacity primary and secondary cooling systems, and the air temperature in the medical center rose
to supplement the facility-level to over 95 degrees with very high humidity. The medical center, the sole level-one trauma
infrastructure. New hospitals must have center in the southwest part of the state, had 41 patients in the ICU who were negatively
their cooling on emergency power due to affected by the rising heat in the facility. Moving ICU patients who are already clinging to
concerns about high humidity and mold/ life can have disastrous consequences, and loss of this facility’s services would have a
mildew impacts on indoor environments
drastic negative impact on the health and welfare of the public in the areas it served.
during extended power outages.
The medical center reached out to the Alabama Department of Public Health’s Center for
Nursing homes and assisted living Emergency Preparedness (ADPH-CEP). ADPH had purchased portable cooling systems for
facilities are often not equipped to their medical surge units with federal Hospital Preparedness Program (HPP) funds. The
provide emergency cooling when grid department was able to deploy these units with an escort from Alabama State Troopers. The
power is lost. While many of these
units were on-site and operational within five hours of the medical center’s request. (United
buildings include operable windows,
States Department of Health and Human Services [HHS], 2009). Evacuation of ICU patients
concerns about patient safety have
was not required.
limited the extent of window operability,
and high humidity climates present a
range of challenges. Certainly, however,
17
resources to adequately heat their the Pacific Coast also experience have been required to meet this level
homes, manage snow removal, and are heavy rains and floods each year from of construction when they were built.
more vulnerable to injury. The National hurricanes that originate in the Gulf of New York City has enacted regulations
Weather Service refers to winter storms Mexico. The Atlantic hurricane season requiring new hospitals to place
as the “Deceptive Killers” because most runs from June 1st to November 30th; infrastructure and essential services
deaths are indirectly related to the storm the Eastern Pacific hurricane season above the 500-year flood elevation to
(NOAA, 2008). Instead, people die in runs from May 15th to November 30th. account for projected sea level rise,
traffic accidents on icy roads and of ensuring that these buildings can
hypothermia from prolonged exposure The vast majority of coastal cities and continue to serve New Yorkers for many
to cold. regions rely upon FEMA Flood Insurance decades into the future. In addition,
Rate Maps (FIRMs) when developing there is growing awareness that hospital
their coastal flood hazard assessments, campuses must be capable of “island”
Tropical Cyclones and zoning regulations and building code operation—that is, able to maintain
Hurricanes, Coastal Storms, and requirements. FIRMs are developed for operational capability even when losing
Surge communities that choose to participate municipal electricity, thermal energy,
A tropical cyclone is a rotating, in the National Flood Insurance water and sewage utility systems for
organized system of clouds and Program; as a result, the requirements extended periods of time. Previous
thunderstorms that originates over for property insurance coverage are tied policy assumed all necessary services
tropical or subtropical waters and has to the elevations outlined by the FIRM. would be restored within 96 hours.
a closed low-level circulation. Tropical Communities also use FIRMs to manage
cyclones rotate counterclockwise in development in and near floodplains. Existing hospital buildings on coastal
the Northern Hemisphere. They are floodplain sites should assess
Many FIRMs date from the late current and projected storm surge
classified as follows:
1970s and 1980s. These maps are data as they undertake infrastructure
• Tropical Depression: a tropical
periodically updated to reflect increased upgrades to ensure that storm surge
cyclone with maximum sustained
understandings gained from actual and coastal flooding do not affect
winds of 38 mph (33 knots) or less
storm experiences, recorded surges, critical building systems, including
• Tropical Storm: a tropical cyclone and development impacts along the generators and information technology
with maximum sustained winds of 39 coastline. New Preliminary Work Maps (IT)/communication systems. Most
to 73 mph (34 to 63 knots) (PWMs) have been released in 2013 hospitals are not mandated to upgrade
• Hurricane: a tropical cyclone with for the New York/New Jersey coast or protect their electrical equipment,
maximum sustained winds of 74 mph to assist communities rebuilding from emergency power systems, and
(64 knots) or higher (in the western Sandy, which represent substantial domestic water pumps to the 500-year
North Pacific, hurricanes are called shifts from previous 100-year and 500- flood elevation; for many, this requires
typhoons; similar storms in the Indian year floodplains. The FEMA Flood Map elevating the equipment, hardening
Ocean and South Pacific are called Service Center (https://msc.fema.gov/ equipment in place (for example,
cyclones) portal) has the most recent information through the use of submarine doors),
• Major Hurricane: a tropical cyclone on FEMA mapping. or dry flood-proofing basements
with maximum sustained winds and lower floors—a prohibitively
Many hospitals constructed in 100-
of 111 mph (96 knots) or higher, expensive undertaking. In order to
year and 500-year floodplains are
corresponding to a Category 3, 4 or 5 avoid evacuation if utility power is lost,
now being required to meet current
on the Saffir-Simpson Hurricane Wind hospitals must ensure that emergency
construction code standards for
Scale (NOAA, 2013) power systems—generators and fuel
flood-resistant construction. This is a
pumps—are accessible to building
All Atlantic and Gulf of Mexico coastal complex requirement, as many hospitals
staff at all times, so that emergency
areas are subject to hurricanes. Parts were constructed under much earlier
power can be maintained continuously,
of the southwest United States and floodplain maps and may or may not
even during flood conditions. To avoid
18
placing an undue financial burden on for standard operational requirements living assistance that is dependent on
providers, hospitals are not required to such as lighting, elevators, water working electricity. For this reason,
retroactively relocate or protect critical pumps, use of medical equipment, and coastal municipalities are beginning
clinical service programs (such as communications, but also for essential to require new facilities either to
emergency departments, lab or imaging emergency operations such as pumping install an emergency generator that is
equipment, or kitchens and laundries) floodwater out of basements if flood adequately protected or to arrange for
for which other workarounds can be protection fails. pre-connection to external stand-by
implemented. Nevertheless, protection generators.
for these critical functional program Because on-site generators may fail
areas should be encouraged as a best when used at full loads for an extended
practice, since they could be essential period of time, coastal hospitals and
for some facilities to remain in operation, nursing home facilities are increasingly
depending on their layout and unique required to have an electrical pre-
risks. Many providers have already met connection for external mobile
these requirements, either because generators. The ability to switch quickly
local regulations demand it or because from the electrical system to a mobile
they are proactively hardening their generator can significantly reduce the
infrastructure based on accumulated likelihood of emergency evacuations
experience. For example, many hospital during or following a disaster. External
generators in coastal areas are elevated. generator connections allow the facility
However, fuel storage tanks, fuel vents, to size on-site generators for code-
and fuel pumps may be vulnerable if required life safety, critical patient care
they remain below flood elevations. equipment (those systems that must be
In addition, power, emergency able to be operational within 10 seconds
power, and water are all necessary to of power loss), and critical medical
support a shelter-in-place situation, support services; additional mobile
and investments in infrastructure generators can be used to handle air
resilience are needed to minimize conditioning and other systems that
future evacuation risk. Accordingly, can tolerate longer disruption. Prior to a
many providers have already assessed major weather event, external generators
their potential vulnerabilities and are can be safely mobilized nearby, and
addressing them. safely deployed once the event has
passed. However, consideration of
Residential care facilities in coastal mobile generators is dependent upon
areas are more vulnerable than those reliable access—such solutions may
located inland. Few coastal states not be appropriate for barrier islands
require the same level of construction or locations that could be rendered
as the Florida example above. Following unreachable by road.
Sandy, New York City is matching
Florida’s mandate that new nursing Adult residential care facilities, such as
homes and intermediate care facilities homes for developmentally disabled,
be constructed with additional resiliency rehabilitation facilities, and assisted
measures for their emergency power living, are not generally required to
and water supply systems, to allow have emergency power systems. Their
staff and patients to shelter in place residents are more ambulatory and
safely during a disaster. Power in these less fragile than nursing home patients,
residential facilities is needed not only but they nevertheless require care and
19
Lessons Learned from Hurricane Katrina

On Monday, August 29, 2005, Hurricane Katrina, the 11th tropical storm of the 2005 season, made landfall as a Category 3 storm east of New
Orleans. Katrina initially caused minimal damage to the operating hospital system, including Tulane’s Medical Center, Charity Hospital, and
Tenet’s Memorial Hospital. The National Hurricane Center’s Tropical Cyclone Report concluded that most of the city of New Orleans experienced
sustained surface winds of Category 1 or 2 strength, so buildings sustained only minimal wind damage. Indeed, most thought that New Orleans
had come through relatively unscathed.
Later that day, levees that were supposed to protect the city failed. Over the next 24-48 hours, several feet of water flooded 80 percent of the
city. Communications systems at all levels were inadequate, so city, state and federal officials made decisions based on information supplied
by television reporters in parts of the city that were not yet flooded. Government officials believed and stated that the levees had held, when in
reality, large segments of the city were under water.
By Monday evening, flood water started to enter Tulane’s University Hospital, The Medical Center of Louisiana New Orleans (MCLNO) Charity
Hospital campus, the Veterans Administration Medical Center (VAMC) and medical school buildings. During that night, basements were filled
with water, and several feet of water flooded the first floor of all the buildings in the downtown medical center. Although only essential clinical
personnel and their families were supposed to enter these facilities prior to the storm, many others sought shelter there.
Initially, emergency generators provided power; however, those generator systems did not include cooling or dehumidification loads, so
temperatures in the hospitals rapidly soared into the upper 90s and were made intolerable by 100% humidity. Lower floors of the buildings were
inundated with backed-up sewage. For several days, faculty, residents, nurses and hospital personnel performed heroically, caring for patients
in appalling conditions. At MCLNO’s Charity Hospital, people threw furniture through the sealed windows to access fresh air.
At Tulane Medical Center, hospital engineering staff fashioned a makeshift helipad on a parking garage roof to evacuate 200 patients and 1500
personnel 48 to 72 hours after the storm, as generators ran out of fuel or failed and it became apparent that no fuel would arrive. Patients were
transported in passenger pickup trucks, as ambulances were too tall to access the parking deck.
Hurricane Katrina left New Orleans in ruins. Following the storm, MCLNO (Charity Hospital) and the VAMC were too severely damaged to make
refurbishing a viable option. Those facilities are instead being reconstructed, sharing some facilities and services. The closure of MCLNO and
the VAMC meant the loss of approximately 70% of Tulane’s teaching beds. The school returned to New Orleans after relocating to Houston for
the 2006 – 2007 academic year. Before Katrina, Tulane’s School of Medicine and School of Public Health and Tropical Medicine trained more MD,
MPH graduates than any other school in the country (Taylor, 2007).
Determining a method for both hazard mitigation and resilience is nuanced and can require important community choices. In 2008, the
National Trust for Historic Preservation placed Charity Hospital and its adjacent mid-city neighborhood on its annual list of “America’s 11 Most
Endangered Places.” Preservation-minded citizens hoped to prevent destruction of 18 square blocks of historic homes and buildings slated
for removal in favor of the new Veterans Health Administration and Louisiana State University hospitals that would replace Charity and the
VAMC. Despite these efforts, construction began on the new complex in January 2013. Local press reported that “an irreplaceable part of the
city’s history was lost, demonstrating that a replacement hospital designed for structural resilience can do as much damage as a hazard with
respect to a local neighborhood.” The set of community health issues that accompany the evacuation and closing of a hospital facility should
be considered as part of a multi- hazard risk assessment process (Rudowitz, Roland, & Shartzer,2006; Hrickiewicz & Kehoe, 2006; Gray &
Hebert, 2006).
20
CASE STUDY: University of Texas Medical Branch (UTMB), Galveston Island, Texas
The University of Texas Medical Branch is a health care campus located on Galveston Island, spanning 85 acres and comprising multiple
hospitals, including a Texas Department of Corrections medical facility, the Level 1 center for a nine-county region, a medical school, and an
assortment of specialized clinics, centers, and institutes. The campus employs 13,000, provides the only health care to the island’s 57,000
residents, and manages 8 million yearly visits.
It houses a high-security national bio-conatinmnet laboratory for Bio-Safety Level 4 research, one of only a few such facilities in the United
States. The campus relies on a shared district infrastructure.
On September 13, 2008, Hurricane Ike hit the Galveston waterfront with 110 mph winds and a 15-foot storm surge, causing $29.6 billion in
damages. It was the third most costly storm in U.S. history. UTMB evacuated the inpatient hospitals before the storm at a cost of $20 million.
By the time the storm passed, nearly every one of the campus’s one hundred structures had sustained damage at a combined cost of almost
$1 billion. Hospital functions and services were shut down for months; the emergency department closed for nearly a year. In the context of the
national economic recession, the situation on the Texas coast faced major hurdles in capital funding. After much discussion by the University of
Texas Board of Regents about the long-term viability of the Medical Branch on the Island, the
decision was made to reconstruct the campus.
The recovery focused on four goals:
• Repairing damaged facilities to pre-disaster conditions
• Improve facilities to better serve UTMB and its customers
• Enhance the resilience of those facilities to reduce the damage from future events
• Maximize FEMA and insurance reimbursement for disaster-related costs
Key elements of the infrastructure replacement included elevation of vulnerable mechanical
and electrical infrastructure above the ground level in the health care core, dry flood-proofing of
radiation oncology treatment rooms, and the creation of a new 6-story clinical services building
to house all the primary functions that were previously on the first floor or lower level of the
eight hospitals in the health care core complex: pharmacology, food services, sterile processing,
blood bank, laundry, and storage. A new ground level concourse, built from water- resistant
Figure 2: The new clinical services
materials, connects the existing buildings; the ground level runs on standalone mechanical and building at UTMB consolidates
electrical services. A 100,000 square foot primary care pavilion was reconstructed with a flood departments formerly housed in
wall to 5 feet above ground level, connecting to a slurry wall 20 feet below grade. All surfaces hospital buildings at or below grade
on floors within 20 feet of grade on all buildings were replaced with water resistant materials.
In addition, UTMB constructed a new district heating plant, complete with an underground distribution system, to allow rapid recovery of
systems for the hospitals. The existing elevated steam and chilled water lines, which were heavily damaged in the storm, were removed. A new
210-bed hospital is under construction. At the same time, UTMB notes that it remains dependent upon critical utilities, including water, sewer,
natural gas, power, telephone and data systems, external to the campus. Hence, they continue to diversify services and expand facilities on the
mainland while mitigating risk on the Galveston Island campus. In a presentation to the American Meteorological Society, Steven LeBlanc, PE,
MBA, Assistant Vice President at UTMB, summarized the lessons learned:
“The storm is just an instance in time; recovery is where all the hard work and decisions are made. Recovery is also where opportunities reside:
sustainable design is a must. Hurricanes come in approximately 20-year cycles; there is a generation to forget what you learned. It is critical to
build to protect the future” (LeBlanc, 2013).
21
Inland Flooding from Extreme

Rain
Heavy precipitation contributes to
increased flooding. This pattern has
already been observed around the
world. The frequency of great floods
(100-year floods in large basins)
increased substantially during the 20th
century. Flooding in large river basins,
such as the Mississippi, is based on
extreme precipitation that is sustained
for weeks or months. In spring, heavy
rains over fallen snow can contribute
to flooding in northern regions. In the
U.S., 90-day periods of heavy rainfall
were 20% more common from 1981 to
2006 than in any earlier 25-year period
on record. Record-breaking Mississippi
flooding occurred in 2008 and 2011
in association with very heavy rains,
followed by extensive flooding further
north in the Missouri River basin due to
heavy rain and snowmelt.
Natural variability cannot explain the

observed changes in precipitation
intensity or geographic distribution Figure 3: The map shows the percentage increases in very heavy precipitation (defined
of precipitation. Rather, the observed as the heaviest 1 percent of all daily events) from 1958 to 2012 for each region. There are
changes follow from basic physical clear trends toward more heavy precipitation for the nation as a whole, and particularly in
principles and are consistent with a the Northeast and Midwest. (Melilo et al., 2014)
combination of natural factors and
human influence. A 4% increase is the result of human activity (Karl et Large river basin flood control has been
in atmospheric moisture has been al., 2008; Stott et al., 2010; Min, Zhang, primarily managed by the U.S. Army
observed, consistent with a warming Zwiers, & Hegert, 2011). Corps of Engineers, as many river basins
climate (Trenberth et al., 2007). The are dammed for agriculture and water
increased moisture in the atmosphere A map that shows increased amounts of withdrawal. Despite this management,
is driving the shift to heavier but less very heavy precipitation across the U.S. large flood events are increasing. The
frequent rains. While an atmosphere suggests that the Northeast has seen the Mississippi River floods in April/May 2008
that holds more moisture has largest increase, followed by the Great and in 2011 were among the largest and
greater potential to produce heavier Lakes/Upper Midwest and Alaska. The most damaging along the waterway in
precipitation, precipitation events also National Weather Service (NWS) has pro- the past century, rivaling and exceeding
become less frequent and shorter, as it vided maps of experimental long-range major floods in 1927 and 1993.
takes longer to recharge the atmosphere river flood risks and national significant
with moisture (Trenberth, 2011). There is river flood outlooks to aid health care or- In April 2011, two major storm systems
increasing scientific consensus that the ganizations in understanding both current deluged the Mississippi River watershed
observed increase in heavy participation and projected risks. with record rainfall. Areas flooded along
22
the length of the river itself in Illinois, and local policymakers to set clear and
Iowa, Missouri, Kentucky, Tennessee, consistent criteria for flood-proofing in
Arkansas, Mississippi, and Louisiana. hospitals and residential care facilities
According to a report compiled by the located on or adjacent to river basin
U.S. Army Corps of Engineers, the event floodplains.
caused $2.8 billion in damage, and
the system of levees, reservoirs, and
floodways was tested as it never had
been previously (Sainz, 2013). Almost
all of the levee or floodwall systems
were damaged. The floodways at Birds
Point-New Madrid in Illinois and the
Morganza Floodway and Bonnet Carre
Spillway in Louisiana were opened to
relieve the stress on the system, marking
the first time that three floodways had
been operated during a single flood.
Cairo, Illinois was saved only by opening
a 2 mile length of a Missouri levee,
sacrificing 130,000 acres of farmland
and 100 homes. Seventeen hospitals
and 11 nursing homes were considered
at a high risk of flooding and 4 health
care facilities were evacuated.
Cities and states have relied upon basin

management agencies to set flood levels
and infrastructure threshold conditions.
Likewise, hospitals have been built in
consideration of such recommendations.
Recent events have exceeded predicted
thresholds, prompting calls for change
in river management practices. Along
the Mississippi River and other river
basins across North America, cities and
counties are buying property to begin
the process of restoring flood plains
and wetlands. While this change in
approach is underway, the impacts from
extreme weather events may produce
unpredictable outcomes.
Given the increase in threshold

values for flood crest elevations
associated with climate change and the
shifting approach to large river basin
management, it is important for state
23
CASE STUDY: Mercy Medical Center, Cedar Rapids, Iowa

Tim Charles, Mercy Hospital’s President and CEO, remembers the 2008 event this way (Ford, 2013):
“We had prepared for all kinds of disasters, but I’m not being at all facetious when I say that flooding and patient evacuation were not in the
game book. We called the staff together and put out a call for employees to help sandbag. I remember saying that we didn’t think we were
going to be affected by water, but we were sandbagging as a precautionary measure.”
When the city’s sewer system was overwhelmed, water began backing up into the lower levels of Mercy. Employees rushed from bathroom to
bathroom, removing toilets and sinks and plugging the holes with towels, sandbags and inflatable rubber bladders. Within hours, the decision
was made to evacuate the remaining 183 patients before potential loss of emergency generators housed in the basement would render
evacuation of the 9-story building more difficult. It took nearly seven hours to move the patients and medical equipment through the halls,
down the elevator, and safely out of harm’s way. Once the building was safely emptied of patients, hundreds of volunteers spent the night
sandbagging to prevent the water from overtaking the facility.
The central power plant for Mercy had been expanded and relocated from its prior basement location to a freestanding central utility plant on
higher ground on the north side of the hospital. Because the plant was undamaged, the hospital was able to reopen in 16 days, once the flood
damage was repaired at a cost of $68 million (Saporito, 2013).
St. Luke’s Hospital, located nearby on higher ground, took 52 of Mercy’s patients and about twelve Mercy nurses to open a vacant nursing unit.
Additional help poured in from everywhere, including what was dubbed the “Big Relief from the Big Easy.” New Orleans medical staff knew all
too well what Cedar Rapids was experiencing—Katrina survivors came with donated items and Cajun home cooking.
As Tim Charles told Iowa Public Television (IPTV 2008):
“Over the next roughly 107 days from the night of the flood we worked diligently with all of the contractors from the local community to reclaim
the facility and to remodel it. We had a theme that we were operating with during this entire time which was we would rise above the flood
better than ever”.
A compelling short film about the 100 days following the flood can be viewed at
http://www.youtube.com/watch?v=buxaMgaT6ls
Since the flood, Cedar Rapids has purchased 1,300 homes and 100 businesses in the flood
plain that was inundated by what the city calls its “800-year-flood.” Mayor Ron Corbett told
the Washington Post “We’re really moving people out of harm’s way” to establish a 220-acre
“floodable greenway” (Vastag and Sellars, 2011).
Figure 4: Mercy Medical Center, Cedar

Rapids, Iowa (2008). Reprinted with
permission from The Cedar Rapids
Gazette.
24
Tornadoes and Extreme Wind a favorable environment for tornado It is not surprising that tornadoes have
formation, but tornadoes also require devastated many hospitals in the last
Events
wind shear, a highly uncertain element in decade. St John’s Regional Medical
Tornadoes are part of severe climate models. Center in Joplin, Missouri (183 beds, see
convective storms, which occur all its case study below); Kiowa Hospital in
over the Earth. In fact, tornadoes Average wind speed over the world’s Greensburg, Kansas (13 beds, see its
have been documented in every state oceans has increased between 5 and case study in Part 3); and Moore Medical
of the U.S. and on every continent 10% over the past 20 years, and the Center in Moore, Oklahoma (30 beds)
except Antarctica. Some parts of speed of extreme winds (the strongest are just three of the many hospitals
the world, however, are much more 1% of winds) has increased by at least that have been damaged by tornadoes.
prone to tornadoes than others: the 15% over the majority of oceans. On More wind resistant requirements for
middle latitudes, between about 30° the other hand, surface wind speed over new residential care settings, including
and 50° North or South, provide the land appears to be declining slightly in nursing homes and intermediate care
most favorable environment for their many mid-latitude locations, including facilities, must also be in place for a
formation. This is the region where cold, the United States. High-altitude generation before resilient care settings
polar air meets warmer, subtropical circulation changes associated with are the norm.
air, often generating convective climate change may affect wind speeds,
precipitation along the collision but land use factors such as urban
boundaries. The areas most frequently development and vegetation growth are
hit by tornadoes are also considered also major contributors to slowing land
the most fertile agricultural zones surface winds.
of the world. The United States has
the world’s highest absolute tornado Tornadoes and extreme wind events
count, with an average of over 1,000 wreak havoc on buildings, particularly
tornadoes recorded each year. Canada those constructed prior to the 1970s,
is a distant second, with around 100 when building codes began to focus on
per year (NOAA, 2014). For data on wind resistance of structural elements
historical tornadoes by state or intensity, such as windows and roofs. Wind tunnel
information about categorization, see modeling has become much more
the NOAA U.S. Tornado Climatology advanced, allowing predictive modeling
website. of the impact of high wind on building
designs and air flow. In order to survive
NOAA reports that there is no clear trend the most severe tornadoes (Enhanced
in the frequency or strength of tornadoes Fujita (EF)-5), facilities must be built
since the 1950s for the U.S. as a whole to withstand wind velocities of 200
(2013). Incomplete and inconsistent miles per hour, with particular attention
record keeping makes it difficult to to fastening equipment and façade
assess how local thunderstorms and elements to minimize the risk of airborne
tornadoes in the United States have debris becoming projectiles in the wind.
been affected by climate change. What
is known is that climate change creates Many U.S. Critical Access Hospitals in
a warmer, moister environment that may tornado-prone regions date from the
fuel additional thunderstorms. Computer 1950s or 60s, prior to contemporary
models of a warming climate indicate codes and standards. Retrofits of
that conditions may become more façades and mechanical systems are
conducive to severe thunderstorms in expensive and complex, particularly for
some regions. Thunderstorms provide hospitals that must remain operational.
25
CASE STUDY: St. John’s Regional Medical Center, Joplin, MO (Mercy Hospital Joplin)
and Freeman Health System, Joplin, MO
In the late afternoon of Sunday, May 22, 2011, a catastrophic EF-5 tornado struck Joplin, Jasper
County, and Newton County in southwest Missouri. With winds in excess of 200 miles per
hour, the 3/4-mile wide tornado cut a 6-mile path of destruction through central Joplin. The
tornado caused 161 fatalities and approximately 1,371 injuries, making it the single deadliest
U.S. tornado since 1947 and the eighth most deadly in history. Thousands of structures were
destroyed or damaged, including single-family homes, apartment buildings, retail stores, and St.
John’s Regional Medical Center. Freeman Health System, a smaller nearby hospital that escaped
a direct hit, responded to this medical surge incident.
The initial priority at Mercy Hospital was a complete, immediate hospital evacuation. At the
time of impact, clinical and nonclinical staff knew to immediately begin evacuation procedures.
Windows were blown out; roof-mounted equipment, and the roofing itself, was dislodged. More
than 183 patients, staff and visitors were evacuated in 90 minutes, safely dodging debris along
the way. Five critical care patients and one visitor died. Within a week, a 60-bed temporary field Figure 5: A photo taken from the roof
hospital was established in the parking lot of the destroyed facility. of Mercy Hospital conveys the scope
of the devastation. The hospital was a
Freeman Health System, the second hospital in the immediate vicinity, was immediately on complete loss.
complete generator power. There was a massive communications failure; all staff was needed,
but because it was Sunday, no OR staff or surgeons were on-site. Within 2-4 hours after the
tornado, an estimated 400 patients were in triage areas, and 120 patients were in the ED. An estimated 70-100 ambulances had arrived to
the area. Within 12 hours post-tornado, water pressure had dropped, and Freeman prepared for an extended water outage (Missouri Hospital
Association [MHA], 2012).
Work on a replacement Mercy Hospital began in 2012; the facility is scheduled to open in early 2015. It will feature two underground levels and
eight levels above ground. Storm-resistant features include laminated glass throughout the facility, hurricane-rated windows in critical areas,
a concrete and brick exterior, two independent electrical feeds, two water supplies, two generators housed in a storm-resistant building (either
generator can power the hospital independently), and interior (storm-resistant) stairwells that are equipped with emergency lighting (Mercy
Hospital Joplin, 2013).
26
Drought
Trends in drought also have strong
regional variations. In much of the
Southeast and large parts of the West,
the frequency of drought has increased
with rising temperatures over the past
50 years. In other regions, such as the
Midwest and Great Plains, droughts are
occurring less often.
Droughts are likely to become more

frequent and severe in some regions.
The Southwest, in particular, is expected
to experience increasing drought as
changes in atmospheric circulation
patterns cause the dry zone just outside
the tropics to expand farther northward
into the United States. Models project
that extreme dust events, combined Figure 6: This chart shows the percentage of U.S. lands classified under drought
with global warming, could advance conditions from 2000 through 2012, according to the U.S. Drought Monitor classification
the spring thaw in the mountains of system, described in the table at http://www.epa.gov/climatechange/science/
the Upper Colorado River Basin by as indicators/weather-climate/drought.html. The data cover all 50 states plus Puerto Rico
many as 6 weeks by 2050. The earlier (United States Environmental Protection Agency [EPA], 2012).
disappearance of snow could amplify
water disputes, extend the fire season,
can effectively reduce potable water While droughts have not, to date,
and place stress on aquatic ecosystems.
demand. Local municipalities may caused severe disruptions to health
Hospitals are generally among the restrict the collection and use of care services, a range of other weather-
top 10 potable water consumers in rainwater. In 2012, Kiowa Hospital (see related water supply disruptions have
their communities. Residential and the case study on page 56) became the led to significant service disruptions.
ambulatory facilities consume far first hospital to use captured rainwater These are documented in Part 3.
less water than hospitals, but require to flush toilets, a system that requires
potable water supplies to operate. The separate water supply plumbing for Wildfires
first step for all health care facilities in toilets. Water conservation can reduce
Higher spring and summer
handling extreme drought is potable water fixture use by 40% or more (which
temperatures, along with an earlier
water conservation: water-efficient is approximately 20% of the total water
spring melt, are the primary factors
fixtures and devices. Moving large use of a facility), and shifting process
driving the increasing frequency of large
process water loads, such as cooling loads to municipal reclaimed systems
wildfires and longer fire season in the
tower makeup water or landscape can double that savings. Water efficient
western U.S. over recent decades, as
irrigation, to municipal reclaimed water landscaping can save an additional 5%,
demonstrated by the record-breaking
sources provides another key strategy particularly in drought-prone regions,
fires in 2013 in the Southwest and Rocky
to operating with radically reduced and using drought-resistant plants is
Mountain Region. The drought, heat
potable water in arid regions. In some a growing trend. There are no specific
wave and associated record wildfires
areas where rainfall is concentrated requirements for on-site water storage in
that hit Texas and the Southern plains
and seasonal, captured rainwater health care facilities, though Emergency
in the summer of 2011 cost $12 billion,
and condensate from air handlers Operations Plans are asked to address
according to meteorologist Steve Bowen
the issue of water supply disruptions.
27
of re-insurer Aon Benfield (Rice and

Raasch, 2012). The 2014 California
drought is estimated to be responsible
CASE STUDY: Memorial Hospital, Colorado Springs,
for $1.7 billion in agricultural losses Colorado
and more than 14,000 associated
In June, 2013, the Black Forest fire claimed two lives, destroyed at least 509 homes, and
jobs (Bernstein, 2014). Increasing
damaged 17 others. An estimated 300 employees from Memorial Hospital and Children’s
temperature peaks correlate with
increasing wildfire vulnerabilities. Hospital Colorado at Memorial were evacuated or pre-evacuated from their homes. When
Memorial Hospital got reports of the encroaching fire, they immediately began preparing
Hospitals may force evacuation when based on their 2012 experience with the Waldo Canyon fire. Each of these fires was larger
wildfires encroach. Hospital ventilation than any preceding fire.
systems require an outdoor fresh air
Memorial’s Safety and Facilities departments began “environmental rounds,” monitoring
supply to maintain indoor air quality and
pressurization; if the outdoor air quality air quality in the buildings. The team placed mobile air scrubbers at Memorial Hospital
is severely compromised by smoke, North, which was nearly full with patients,
it may be impossible to safely house and at Memorial Hospital Central. Memorial
patients and staff in the building. Forest worked with building managers at off-site
fires have caused a number of planned, locations to maintain air quality in those
limited duration evacuations in the U.S., buildings. Outside, the sky turned pewter in
most recently at Camp Pendleton Naval color, as it had on June 26, 2012 when the
Hospital in California and St. Luke’s Waldo Canyon Fire roared into the Mountain
Wood River Valley Medical Center Shadows subdivision, killing two people and
in Idaho. However, hospitals remain destroying 347 homes.
important in fire areas in order to treat
firefighters and residents; hospitals
in fire-prone areas should consider
isolating emergency department
ventilation systems and enabling
recirculated air during emergency
conditions. In addition, portable Figure 7: A view of the approaching
scrubbers can be placed in nursing
forest fire from the Memorial Hospital
Helipad.
units to improve air quality once outdoor
ventilation systems must be shut down.
28
evacuated in June, 2014 when a 100

yard section of embankment directly
CASE STUDY: Providence Holy Cross Medical Center, adjacent to the hospital campus gave
Burbank, CA way following 3-6” of rainfall in a single
day, the worst single rainfall event since
In 2008, two wildfires affected southern California: the Sesnon fire (a natural fire in October
1871 and the culmination of the wettest
that lasted 5 days) and the Sayre fire (an arson in November that lasted 6 days). The Sesnon
June on record.
Fire resulted in $12.6 million in damages. The main threat to Providence from this fire was
smoke, not fire. The Sayre fire was more intense. It crossed a highway, preventing 40% of Soils that are loose and saturated
the medical staff from reaching the facility. The fire caused $13 million in damages. with water are prone to liquefaction.
While liquefaction is particularly
Providence Holy Cross Medical Center, the only local area trauma center in Burbank,
associated with seismic events, it
received more than 200 patients from neighboring hospitals and canceled all elective
can also occur along shorelines and
surgeries. Providence was able to stay open and operational during both fires, thanks following periods of intense rainfall. Soil
in large part to the use of HEPA filters. These filters were purchased for pandemic flu liquefaction can significantly damage
preparedness to purify the air and to support the central ventilation system for maintaining the built environment. Buildings whose
zero pressures (which is critical for quarantine rooms). In this case, the utilization of foundations bear directly on sand that
equipment intended for one purpose actually helped the hospital remain open and liquefies will experience a sudden loss of
functional during a fire/weather event (Thomas, 2011). support, resulting in drastic and irregular
settlement of the building causing
structural damage, or may leave the
structure unserviceable afterwards, even
without structural damage.
Landslides, Liquefaction, and result in an estimated 25 to 50
Avalanches deaths a year. However, they remain An avalanche is a rapid flow of snow
relatively understudied. While in the down a sloping surface. While some
With increasing extreme rainfall and past, landslides have generally been
snowfall events, the risk of landslides, avalanches are caused by human
associated with seismic events, activities, in some cases they may
liquefaction and avalanches may also tsunamis or volcanic eruption, increased
increase. In a landslide, masses of rock, result either from weakening in the
precipitation and land mismanagement, snowpack or increased load due to
earth or debris move down a slope. particularly in mountain, canyon and
Debris and mud flows are rivers of rock, precipitation. Avalanches that occur
coastal regions, has increased focus in this way are known as spontaneous
earth, and other debris saturated with on landslide vulnerabilities. In areas
water. They develop when water rapidly avalanches. Generally, once initiated,
burned by forest and brush fires, a avalanches grow rapidly as they entrain
accumulates in the ground, during heavy lower threshold of precipitation may
rainfall or rapid snowmelt, changing the more snow. In mountainous terrain,
initiate landslides. Mapping of landslide avalanches are among the most serious
earth into a flowing river of mud or “slurry.” vulnerabilities is conducted sporadically,
They can flow rapidly, striking with little objective natural hazards to life and
often at a regional or even site-specific property, with their destructive capability
or no warning at avalanche speeds. They level. Some regions of high seismicity
also can travel several miles from their resulting from their potential to carry
have developed maps of the areas enormous masses of snow at high
source, growing in size as they pick up susceptible to landslides based on
trees, boulders, cars and other materials. speeds. There is no universally accepted
average slopes, geologic soil types, and classification of avalanches—avalanches
Landslides may damage properties the past history of sliding. Sites within
directly in the path of travel of the slide, or can be described by their size, their
these susceptible zones require site- destructive potential, their initiation
disrupt roads and critical infrastructure. specific investigation. A small ancillary mechanism, their composition and their
office structure on the University of dynamics. In areas prone to avalanches,
Nationally, landslides account for
Minnesota Medical Center was partially a range of mechanical mitigation
over $2 billion of loss annually and
29
measures can be deployed, ranging components of a building or institution equipment, while the ductwork is
from use of explosives to snow fences structure. Foundations, bearing walls, susceptible to collapse once the building
to avalanche dams. columns and beams, staircases, floors enclosure is penetrated. Airborne debris
and roof decks, or other types of from windstorms or forest fires can
structural components that help support quickly clog the air filtration systems,
INSTITUTION-LEVEL a building are structural components. rendering them impaired or inoperable.
Applied to site planning, structural
INFRASTRUCTURE: components may include roads, vaults, Hospitals and other residential care
ASSESSING HAZARDS or bridges. The structural aspects of facilities depend on several essential
AND VULNERABILITIES design and construction in most hazard- pipe systems. Medical gases are among
prone areas are regulated by building the most important substances that
Climate change considerations should
codes and other regulations. Such must be channeled through pipes, along
be integrated into institutional-level
codes are usually prescriptive in nature: with water, steam, and fire sprinkler
hazard and vulnerability assessments
they establish minimum requirements systems. Physicians and nurses depend
that are conducted as part of
that are occasionally updated with on oxygen and other gases for patient
preparedness planning for extreme
newly-acquired knowledge. The building care. Unless properly secured and
weather. Consideration of how climate
regulations alone, however, cannot braced, these installations can be easily
change may enhance the weather
guarantee uninterrupted operation of a dislodged or broken, causing dangerous
hazards chronicled above, overlaid on
hospital or residential health care facility, leakage and potential additional damage.
the health care delivery setting (hospital,
nursing home, intermediate care), is because many other factors affect
In floods, stormwater management is
an important first step in assessing hospital functions.
critical – as rainfall events intensify in re-
infrastructure’s vulnerabilities to extreme gions of the U.S., roof drainage systems,
weather hazards. Non-structural Vulnerability stormwater retention basins and drywell
The effects of damage to non-structural systems may overflow and cause local-
Institutional health care infrastructure
building components and equipment, ized flooding and water damage. Sewers
can be divided into three types:
as well as the effects of breakdowns in are apt to overflow, back up, or break
structural, non-structural, and
public utility services, communication/ down. Waste disposal is essential for any
operational (FEMA, 2011). This Guide
IT infrastructure, transportation, re- residential health care setting, because
and Toolkit addresses structural
supply, or other organizational aspects when the toilets back up, or sterilizers,
and non-structural infrastructure,
of hospital operations, can be as dishwashers, and other automated clean-
but since operational needs often
disruptive and dangerous to patients as ing equipment cannot be discharged,
drive non-structural decisions, those
any structural damage. Non-structural patient care is immediately affected.
considerations are also addressed
components include architectural Retention ponds or holding tanks, cou-
to some degree in this resource. For
components, such as exterior walls, pled with backflow and diversion valves,
example, hospitals and long-term
window and roofing, as well as interior can be employed to solve this problem.
care facilities need to provide secure
components of buildings, such as However, in many health care facilities,
housing for staff and their families in
suspended ceilings. Collapse of these this issue has not been adequately
an extreme weather emergency; this
components has caused a number of addressed. Landscape and advanced
need may drive co-development of
evacuations and closures of hospitals stormwater management techniques
hotel facilities or contracts with existing
following a hazard event. can improve groundwater infiltration and
neighboring hotels that can be activated
reduce surface runoff and flooding.
in emergency planning. Ventilation systems are extremely
vulnerable to disruption as a result of Elevator service is vulnerable not only to
Structural Vulnerability indirect building damage. Winds often power outage, but also to direct damage
Structural vulnerability considers overturn improperly attached roof- to elevator installations. Wind and
potential damage to structural mounted ventilation and air conditioning windborne debris can damage elevator
30
penthouses, opening a path for water can impair hospital functions as much as and long-term care facilities must
penetration that can disable elevator physical damage. have effective plans to house up to
motors and controls, as has happened 1,000 additional people nearby, out
during recent hurricanes. Flooding of Any prolonged isolation or blockage of of harm’s way, in buildings that have
elevator pits was a common problem streets serving a residential health care power, water, and services. Health care
during Hurricane Katrina and Superstorm facility can impair supply replenishment, facilities in disaster areas are creating
Sandy, and it is often responsible for the including fuel for emergency power innovative partnerships with hospitality
loss of elevator service. generation. Following Hurricane Katrina, and housing organizations to quickly be
many hospitals were isolated by able to mobilize additional housing units.
The emergency power supply system floodwaters for five or more days and, in Community Hospital at Toms River, New
is probably the most critical element many cases, could not replenish critical Jersey purchased 100 pet crates to
of a health care system. Together with supplies, which in some instances enable staff to safely move their house
fuel supply and storage facilities, this contributed to the decision to finally pets to the hospital when their families
system enables all the other hospital evacuate the facility. were evacuated after Superstorm Sandy.
installations and equipment that
have not sustained direct physical Ultimately, workers, from clinical care Finally, climate considerations call
damage to function normally in any staff to food service personnel to envi- into question how long emergencies
disaster. As the nature of diagnosis and ronmental services workers, keep health must be managed. Four days, five
treatment becomes more dependent care facilities functioning. Personnel stay days— there are stories of facilities
on computers, monitors, and other past their shifts or arrive early in order to that safely harbored in place for more
electrical equipment, the need for help transfer fragile patients from facilities than 100 hours, only to finally need to
emergency power will continue to grow. in flood zones. During the height of the evacuate due to organizational failures.
The experience of Hurricane Katrina Superstorm Sandy, NYU Langone Med- Community Hospital at Toms River
demonstrated the need for emergency ical Center’s personnel evacuated the (profiled on page 60) pre-ordered
power coverage even for services that hospital, carrying sick patients down the supplies before the storm hit, and
typically have not been regarded as stairs into awaiting ambulances. Many converted conference facilities to store
critical in both hospitals and residential nursing home employees worked 36-hour them. The question of duration is a key
care facilities, such as climate control shifts due to staffing shortages and loss one for facility owners and policymakers
and air conditioning systems. Extreme of services. Both in acute care and resi- moving forward in improving resilience.
heat caused a number of hospitals to dential settings, health care workers are
evacuate their patients and staff when first responders, engaging in lifesaving It is imperative to recognize the role
the conditions became unbearable. measures that may expose them to dan- of front line health care workers, from
gerous conditions or injury. Hence, the clinical care to environmental services
organizational vulnerabilities must include workers, and the broader community
Organizational Vulnerabilities assessment of the potential workplace in planning for enhanced organizational
Most health care organizations have hazards that may arise in emergencies, resilience. Front-line workers should
disaster mitigation or emergency and planning should address measures participate in the development of
operation plans, but not all of them to mitigate those hazards. For example, health care risk assessment and
provide organizational alternatives if hazardous materials are stored in areas emergency plans, in risk assessment
when the normal daily movement prone to flooding, and personnel must and emergency plan reevaluations
of staff, patients, equipment, and access those areas during a flood for and update, including lessons learned
supplies are compromised. The critical operational tasks, how are they after specific emergency events. The
critical nature and interdependence of protected? broader community may offer both
these processes represent a separate organizational assets, and require
category of vulnerabilities that need Likewise, the need to safely care for the supplies or services, during and after
careful attention. The disruption of families of workers during emergencies an event. For example, a volunteer
administrative services by natural events cannot be underestimated. Hospitals community organization called “snow
31
angels” mobilized to transport hospital to climate resilience as follows: well as storm surge and wave impacts
workers to and from Jefferson Medical associated with coastal storms. For
“Transportation systems are potentially
Center during West Virginia’s 2014 example, storm surge can damage
ice storms, when hazardous driving
vulnerable to the loss of key elements. and destroy coastal roadways, bridges
conditions reduced mobility (Vincent, Therefore selectively adding redundant and airports, and sea level rise could
2014). At the same time, disruption of infrastructure may be a more efficient exacerbate such effects.
potable water services, food supplies, or strategy than hardening many individual
other community necessities may bring
facilities on the existing system.
the community to the door of a hospital SPECIAL SECTION:
seeking assistance. Hence, it is critical System resilience is best viewed across
to understand the broader operational
SUPERSTORM SANDY
transportation modes and multiple system
expectations during and after events. AND NEW YORK CITY
owners. While some key elements are
obvious, other dependencies may be less “In keeping with the overarching goals of
Transportation and Site Access the Special Initiative for Rebuilding and
well recognized” (U.S. Department of
Transportation infrastructure is inher- Resiliency—to minimize the impacts of
Transportation, 2011).
ently long-lived. Bridges, tunnels, ports,
climate change and enable quick recovery
and runways may remain in service for Road and rail systems are vulnerable
decades, while rights-of-way and specific after extreme weather events—the City of
to extreme heat, buckling rail track,
facilities continue to be used for transpor- and asphalt breakdown. More air New York will make the health care system
tation purposes for much longer. In ad- conditioning loads in transit can more resilient. To ensure that hospitals,
dition to normal deterioration, transpor- overload power grids, causing nursing homes, and adult care facilities can
tation infrastructure is subject to a range brownouts and power failures. Excessive
of environmental risks over long time operate continuously during extreme weather,
heat can cause signal or electrical
spans, including wildfire, flood, landslide, equipment breakdowns. Increasing the City will require that new facilities be built
geologic subsidence, rock falls, snow, temperatures may create greater to higher resiliency standards and existing
ice, extreme temperatures, earthquakes, demands from hydroelectric systems providers are hardened to protect critical
storms, hurricanes, and tornadoes. that depend on water flow, which
systems” (The City of New York, 2013).
may reduce the water available for
Existing infrastructure has been built to
commercial shipping. A vast, complex health care system
many different design standards, and its
current and future environmental risk is has evolved to meet the needs of New
Severe precipitation that causes flooding
similarly varied. As environmental risks York’s diverse 8.2 million people, and
of roadways, tunnels, and evacuation
change, the probability of unexpected Superstorm Sandy caused disruptions
routes can reduce the life of highway
failures may increase. Further, as across that system. The City of New
infrastructure. It can also increase road
existing infrastructure approaches York Special Initiative on Rebuilding and
washout, landslides, and mudslides
the end of its service life, decisions Resiliency (SIRR) report summarized the
that damage roadways and overloaded
about replacement or abandonment situation:
drainage systems, causing traffic
should, but may not currently, account backups and street flooding. Rising sea “The storm completely shut down six
for changing future risks. In reviewing levels can affect transit agencies on hospitals and 26 residential-care facilities.
transportation infrastructure for critical the coast, disrupting rail and roadways. More than 6,400 patients were evacuated
health care delivery, it is important to Some of these effects, such as sea level
understand the underlying vulnerabilities through efforts coordinated by the Health
rise and increased precipitation intensity,
of tunnels, bridges, access roadways, present greater challenges to the care Evacuation Center (HEC). Providers
and, where applicable, public transit transportation system and infrastructure who remained open strained to fill the
services. The U.S. Department of when combined with subsidence of the health care void—hospitals repurposed
Transportation summarizes its approach land and vulnerable local geology, as
32
lobbies as inpatient rooms, adult care Sixty-one nursing homes and adult care ground floors, electrical switchgear,
facilities siphoned gas from vehicles to run facilities were in areas impacted by and heating/cooling systems, was
power outages and/or flooding. Half of the secondary reason. In ambulatory
emergency power generators, and nursing
these providers continued to operate— settings, the disruption to staff and
home staff lived on-site for four or more some because they sustained minimal patient travel became the primary
days until their replacements arrived” (The or no damage, others because they had reason for disruption, followed by
City of New York, 2013). effective emergency plans. But within a loss of communication/IT systems.
week of the storm, 26 facilities had to While hospitals also experienced
Five acute care and one psychiatric be shut down, and another five partially these outages, there were acceptable
hospital were evacuated—a total of workarounds (battery radios, for
evacuated, which reduced citywide
2000 patients. Three hospitals closed example) in place.
residential capacity by 4,600 beds and
in advance of the storm: New York led to the evacuation of 4,500 residents. Based on the damage sustained after
Downtown (Manhattan) closed after Although two nursing homes and one this “storm of the century” struck, the
notice of a potential pre-emptive utility adult care facility evacuated patients City attempted to assess the future risk:
district steam shutdown, while the in advance of the storm, 28 others
Department of Veterans Affairs’s New evacuated under emergency conditions. “Preliminary Work Maps (PWMs) from the
York Harbor Hospital (Manhattan) These stressful emergency scenarios
and South Beach Psychiatric Center
Federal Emergency Management Agency
added significantly to patient risk, but
(Staten Island) closed due to concerns (FEMA) place at least 300 more buildings,
fortunately there was no loss of life
about possible flooding. Three other during any Sandy-related evacuations in housing, and health care providers in
hospitals—New York University’s the city. the 100-year floodplain than were in the
Langone Medical Center (Manhattan),
floodplain in the 1983 Flood Insurance
Bellevue Hospital (Manhattan), and These closures affected hospitals as
Coney Island Hospital (Brooklyn)— well, preventing them from discharging Rate Maps (FIRMs). Based on high-end
evacuated during or after Sandy due patients to nursing homes as they projections for sea level rise from the New
to the failure of multiple electrical normally would have done. Instead, York City Panel on Climate Change (NPCC),
and mechanical systems, including hospital beds that could have been
another 200 facilities will be in the 100-year
emergency power systems. In the available for new patients remained
occupied by existing nursing home floodplain by the 2020s, and a total of 1,000
immediate aftermath of Sandy, hospital
bed capacity was down 8% citywide. patients. Hospital and nursing home health care facilities will be in the 100 year
closures disrupted health care service floodplain by the 2050s” (The City of New
While ten hospitals remained open, delivery for months following the October
York, 2013).
some sustained minimal flooding event—some hospitals remained closed
damage or operated on emergency for more than 100 days. The report concluded that the location of
generators due to the widespread utility health care infrastructure, in its present
Their summary findings (Figure 8) of
power outages throughout the city that condition, poses unacceptable risks to
reasons for disruptions and evacuation
continued for seven days—dealing with the health and safety of New Yorkers.
are instructive for all health care
volume surges from storm victims and As a result of this work, the SIRR
providers.
closures. Others narrowly escaped flood recommended 14 initiatives, including
damage. For example, Metropolitan Without exception, the loss of (or lack the following:
Hospital in upper Manhattan just missed of) emergency power following the • Initiative 1 (enacted): new hospital
having its critical electrical systems loss of municipal grid power was the buildings will be required to meet
flooded, and floodwaters came within primary reason that hospitals, adult care construction code standards for
inches of the entrance to Staten Island facilities, and nursing homes evacuated. flood-resistant construction to the
Flooded critical infrastructure, such as 500-year flood elevation, which is a
University Hospital’s north campus.
higher than the 100-year flood
33
elevation to which protection is including placing additional systems

required today. on generators as well as installing
• Initiative 2 (slated): existing external portable generator hookups.
hospital buildings in today’s 500- • Initiative 5 (slated): require
year floodplain will meet, by 2030, a retrofitting of existing nursing homes
subset of the amended New York City in the 100-year floodplain by 2030
Construction Code standards through to meet standards for protection of
building retrofits. electrical equipment and emergency
• Initiative 3 (enacted): support power systems, including external
Health and Hospital Corporation’s hookups.
efforts to protect existing emergency This assessment and the follow-up
departments located below the 500- actions demonstrate how health care
year floodplain elevation to ensure providers and policymakers can evolve
availability. resilience measures to meet future
• Initiative 4 (enacted): new nursing weather risk challenges.
home facilities in the 500-year
floodplain will be constructed with
additional resiliency measures for
their emergency power systems,
Primary reason for disruption Secondary Reason Tertiary reason
Figure 8: This table indicates the top three causes of disruption to health care delivery in the aftermath of Superstorm Sandy, including
hospitals, nursing homes, community, and home-based providers (The City of New York, 2013).
34
PART 3: SOLUTIONS FOR THE FUTURE

INFRASTRUCTURE SOLUTIONS FOR IMPROVED
HEALTH CARE CLIMATE RESILIENCE
“The past practice of rebuilding for the Key lessons emerge when reviewing disasters (Dosa et al., 2011; Hyer,
most recent disaster will increasingly leave post-disaster health care failures and 2013).
evacuations: • Increasing energy demands at
communities vulnerable to future hazards,
• For critical health care facilities such academic health center campuses,
and to the consequences from climate as hospitals, it may no longer be which provide patient care,
change and rising sea level. As resources adequate to depend upon current education, and research facilities,
become scarce, communities will be less external community or regionally contribute to the growth of on-site
based mitigation strategies. Hospitals power and thermal energy generation
able to repeat unsustainable or non-resilient
should plan to remain operational as backup to grid-supplied energy
approaches to community development. Yet, even when these larger regional sources for enhanced reliability and
many communities are not now aware of systems fail. Unlike the earlier reduced greenhouse gas emissions.
their options for improved resilience” (Ewing generation of hospitals that failed Emerging technologies, from
after Hurricane Katrina, new hospitals combined heat and power to fuel
& Synolakis, 2010).
in New Orleans are constructed cells, provide reliable forms of on-site
“upside down”: essential medical electrical generation in both normal
services and infrastructure are at and extended emergency operation.
OVERVIEW higher elevations to anticipate a While these systems do not replace
The unprecedented number of weather- failure of the levee system. Architect the need for diesel generators, the
related disasters with total damages Thomas Fisher, in Designing to ability to “island” this distributed
in excess of $1 billion between Avoid Disaster (2013), reminds us generation during extended outages
2011- 2013 has undoubtedly fueled that “going forward, good design provides additional energy resilience.
interest in resilience of facilities and and planning will be based on the • Duplicative emergency power
communities, including health care understanding that nothing will work systems that deliver little to no value
facilities. The combined financial and as planned, or even at all.” during normal, day-to-day operation
health impacts of these extreme weather • For critical health care facilities, it are less likely to attract adequate
events on hospital evacuation and is no longer acceptable to design investment and maintenance from the
nursing home damage is resulting in new buildings using current disaster private sector. Therefore, such on-site
renewed emphasis on developing and thresholds. Planning must recognize systems will be built and maintained
promulgating infrastructure solutions that hospitals have a minimum life of as cheaply as possible, and are likely
for health care climate resilience. These 50 years. Health care organizations to have a high rate of failure during
events have also provided opportunities should use predictive climate extended emergencies. Particularly
to learn from past disasters so models to set design values, such as as resilience strategies move out
that health care facilities, and the maximum outdoor air temperatures for from hospitals into sub-acute and
communities they serve, can be more load sizing, maximum rainfall events residential settings, creative and
resilient in the future. for stormwater systems, projected sea innovative system solutions that
level rise for minimum elevations, and deliver value at all times should be
Large hazardous events will occur and
maximum wind speeds for enclosures prioritized. For example, Florida
will inevitably cause some damage,
of critical spaces. allows residential facilities to include
but these events need not result in
catastrophic losses or total debilitation. • Because recent research and an external generator connection
Storms, hurricanes, and tornadoes are experience suggests that shelter-in- rather than requiring on-site
not avoidable, but their consequences— place is the safest long-term option generator equipment; private vendors
the loss of human life, property, and for residential settings, specific can move mobile generator capacity
essential services—can be avoided infrastructure improvements are from disaster to disaster.
or reduced when a facility and the required to ensure availability of
Indeed, the collective experience
organization that manages it are resilient. primary power, emergency power,
from recent extreme weather events
and water during and following
35
underscores the need for an expanded discussion of embedding resilience Management Committee [NEMC],
approach to health care resilience. in infrastructure decision making. The 2009) includes the following four core
Health care infrastructure must role of the hospital as an important features in its description of a resilient
embrace sustainable site planning regional resource is becoming far more community:
and infrastructure solutions that both prominent, and the reconsideration • functioning well while under stress
mitigate potential extreme weather of health care facilities as potential • successful adaptation
impacts and support the continued, “safe harbors” offers a model for
• self-reliance
uninterrupted functioning of hospitals related community planning initiatives.
and residential health care facilities Weaving neighborhood and community • social capacity
long after the immediate threat has benefits into health care campus design
What are the principles around which
passed, until normal or “new normal” produces an effectively functioning
resilient systems are designed? The
infrastructure services resume. facility as well as a lasting anchor for
non-profit Resilient Design Institute
Personnel responsible for making a community health and resilience.
offers ten principles to inform resilient
health care facility safer for patients,
design thinking in the future (see
more resistant to damage, or capable of
following page). These principles can
continued operations in a post-disaster RESILIENT DESIGN be applied at an individual building,
situation must consider the following
questions (FEMA, 2011):
PRINCIPLES campus, community, or global scale.
• What types and magnitudes of “A resilience-based approach focuses on

hazard events are anticipated at the learning how to respond, adapt to and evolve
site?
with change and surprise, while avoiding
• What are the vulnerabilities of the
changes that would move local and global
site or existing building to natural
hazards? social–ecological systems closer to tipping
• What are the anticipated frequencies points that would threaten the life-supporting
of hazard events? and life-enhancing capacity of these
• What level of loss/damage/disruption/ systems”(duPlessis, 2012).
injury, if any, is acceptable?
In an era of increasing severe weather,
• What might be the financial impact
resilient design principles are being
of extended downtime on the
developed to guide future construction.
institution?
Literature on resilience thinking
• What is the impact to the community emphasizes that a resilient building
if the hospital cannot maintain opera- or development is one that improves
tions in the aftermath of a disaster? opportunities post-disaster through
adaptation. The most resilient are able to
This section examines new and
mitigate and minimize damage, provide
emergent practices that integrate
support and emergency services, and
sustainable design strategies and
take advantage of the post-disaster
resilience thinking in 21st century health
situation to improve or facilitate positive
care building infrastructure. It begins
change economically, socially and
with defining five elements of enhanced
ecologically (duPlessis 2012; Larsen et
infrastructure climate resilience,
al., 2011).
continues with an examination of each
infrastructure system on a typical health The Australian National Strategy for
care campus, and concludes with a Disaster Resilience (National Emergency
36
Resilient Design Principles

1. Resilience transcends scales. Strategies to address resilience apply to individual buildings, communities, and larger regional and
ecosystem scales; they also apply on different time scales, from immediate to long-term.
2. Resilient systems provide for basic human needs. These include potable water, sanitation, energy, livable conditions
(temperature and humidity), lighting, safe air, occupant health, and food; these should be equitably distributed.
3. Diverse and redundant systems are inherently more resilient. More diverse communities, ecosystems, economies, and social
systems are better able to respond to interruptions or change, making them inherently more resilient. While sometimes in conflict with
efficiency and green building priorities, redundant systems for such needs as electricity, water, and transportation improve resilience.
4. Simple, passive, and flexible systems are more resilient. Passive or manual-override systems are more resilient than complex
solutions that can break down and require ongoing maintenance. Flexible solutions are able to adapt to changing conditions both in the
short- and long-term.
5. Durability strengthens resilience. Strategies that increase durability enhance resilience. Durability involves not only building
practices, but also building design (beautiful buildings will be maintained and last longer), infrastructure, and ecosystems.
6. Locally available, renewable, or reclaimed resources are more resilient. Reliance on abundant local resources, such as
solar energy, annually replenished groundwater, and local food provides greater resilience than dependence on nonrenewable resources or
resources from far away.
7. Resilience anticipates interruptions and a dynamic future. Adaptation to a changing climate with higher temperatures, more
intense storms, sea level rise, flooding, drought, and wildfire is a growing necessity, while non-climate-related natural disasters, such as
earthquakes and solar flares, and anthropogenic actions like terrorism and cyberterrorism, also call for resilient design. Responding to
change is an opportunity for a wide range of system improvements.
8. Find and promote resilience in nature. Natural systems have evolved to achieve resilience; we can enhance resilience by applying
lessons from nature. Strategies that protect the natural environment enhance resilience for all living systems.
9. Social equity and community contribute to resilience. Strong, culturally diverse communities in which people know, respect,
and care for each other will fare better during times of stress or disturbance. Social aspects of resilience can be as important as physical
responses.
10. Resilience is not absolute. Recognize that incremental steps can be taken and that total resilience in the face of all situations is not
possible. Implement what is feasible in the short term and work to achieve greater resilience in stages.
Reprinted with permission of the Resilient Design Institute (2014).
37
This Guide and Toolkit is focused at the improvement of resilience in health

the building and campus level. At the FRAMEWORK FOR care institutions for today and tomorrow.
same time, it recognizes that hospital CLIMATE RESILIENT Each of these elements is described in
campuses and health care delivery detail below, with case study examples
is situated within communities, and
HEALTH CARE SETTINGS provided to illustrate applications. The
residential and ambulatory care settings Today there are many examples of Toolkit supports further exploration of
beyond the hospital offer important resilience principles being incorporated each element.
community services. Moreover, a single in new and existing health care buildings
health system may include multiple in the U.S. and beyond. This Guide and It is understood that these five elements
hospital campuses in distinct and Toolkit captures and illustrates these are nested within a broader framework
diverse communities; as health systems principles and practices for health care that begins with institutional and
undertake resilience planning efforts, a settings in a five-element framework administrative support for broader
keen understanding of the relationship (see Figure 9), adapted and modified disaster or emergency preparedness
of the health care settings to individual from a broader UN framework for efforts, and includes education and
communities is essential. community resilience (UNISDR, 2012). training as well as disaster response,
The goal of this framework is to facilitate recovery, and rebuilding, all of which
Figure 9: The five elements of climate resilient health care infrastructure form the basis for exploring a facility or campuses responses to
the challenges of climate change and extreme weather.
38
are outside the scope of this Guide These contextual considerations may Planning should anticipate that hospital
and Toolkit. By focusing specifically be particularly relevant in comparing the buildings will operate for their full life
on improving health care infrastructure needs of urban and rural facilities—for cycles, 50 to 75 years. For sub-acute
resilience, this Guide and Toolkit aims example, during or following a disaster a and other residential health care uses
to reduce future vulnerabilities and rural community may rely on its hospital such as long-term care, a 30-year
loss, and improve the functioning of for essential community services, such planning horizon may be sufficient. Such
a broad range of health care facilities as food, water or basic shelter, while an planning requires significant review of
and organizations in the face of climate urban setting may provide residents with climate change scenarios, including both
change and more extreme weather a wider array of options. effects on weather extremes as well as
events. projected sea level rise.
Other vital assessment steps include
reviewing community vulnerability The basic components of climate risk
Element 1: Multi-Hazard assessment reports and findings. assessment include:
Assessment: Understanding Similarly, it is important to meet with • Historic loss data: Consult or
Climate Risks and Community local and regional governing authorities maintain an updated database of
Vulnerabilities or planning departments to understand extreme weather losses from past
If health care organizations lack a basic preferred local and regional risk events on your campus, city or
understanding of the present and future assessment methodologies and tools. region.
climate risks they may face, planning For example, the state of Florida • Hazard assessment: Establish and
for disaster risk reduction may be requires SLOSH modeling for map the intensity and probability of
ineffective. Relying only on municipal establishing storm surge and inundation, extreme weather events (see Toolkit
codes and regulations places critical while New York City uses Flood and Figure 10 below).
facilities at risk. Risk analysis and Insurance Risk Maps (FIRM’s) and
• Capacity assessment: Identify
assessments are essential to informed applies additional factors for sea level
the capacities and resources
decision-making, prioritization of rise. Additional technical expertise may
available within your organization,
projects, and longer-range planning. be available through local universities,
neighborhood or community to
For example, UT Galveston (see case municipal planning departments, or
provide redundancy in order to
study on page 21) made an informed consultants.
enhance resilience.
decision to diversify and expand its
• Community Vulnerability
facilities on the mainland following the NOAA’s National Weather Service has assessment: Identify the degree
extreme flooding of Galveston Island. resources that explain coastal and of vulnerability and exposures
Health care organizations should
riverine flooding, tornadoes, hurricanes, to hazards your community may
conduct a Climate Risk Assessment (see drought, and wildfire risks. Climate face, and the likely impact of that
Figure 10 and Toolkit) so that they may change scenarios and climate models vulnerability on both medical services
better understand and catalog present are also available to assist property (patient surge) and non-traditional
and future extreme weather risks. owners in understanding future risks needs (beyond clinical care) the
Hospital and health systems that operate (in this case, to 2050 or 2080). The community may expect a medical
multiple campuses (in many instances University of Michigan and U.S. Green facility to provide.
across varying climate zones) should Building Council have published a • Campus Vulnerability assessment:
complete climate risk assessments for major resource for understanding Determine the degree of vulnerability
all their sites. Hospital systems should regional climate change and its impact and exposure to the hazard your
carefully consider how each campus on the built environment (Larsen et. al., campus or building(s) may face (bring
interacts with its community, as well 2011) for all regions of the country. forward conclusions from Element 2).
as how resources and capacity might
shift if extreme weather affects some The need to embrace a multi-hazard
or all of a system’s regional assets. approach is essential, especially for
39
facilities located in areas that may be

exposed to a variety of hazards. While
this Guide and Toolkit focuses on
climate-related hazards, hospitals must
consider a broad range of additional
risks, from bio-terrorism to pandemics.
Multi-hazard assessments can reveal
potentially conflicting effects of
mitigation measures. Thus, the results of
a climate risk assessment should be
included in an organization’s larger
Hazard Vulnerability Analysis. The
importance of this has become
increasingly evident following the
catastrophic failures that have occurred.
“The aim should be to anticipate and

coordinate how the building and its systems
interact, how mitigation of the risk from
one hazard can influence the building’s
vulnerability to others, and how undesirable
conditions and conflicts may be avoided or
resolved. Through the application of a multi-
Figure 10: A sample checklist to assist health care organizations in aggregating climate
hazard and multi-disciplinary approach, cost
risk across a range of extreme weather hazards.
savings, efficiency, and better performance
can be achieved in programming and
planning new buildings and retrofitting facilities should include community
existing ones” (FEMA, 2011). stakeholders, and develop the
assessment in partnership with the
Developers of risk assessments broader community, state or regional
should engage and gather input from, hospital/health care associations, local
at a minimum, Safety/Emergency and regional governments, and public
Management, Transport, Critical clinical health agencies.
department personnel (including
Labs and Pharmacy, Respiratory
Therapy), Support Services (Laundry,
Environmental Services, Food Service),
Infection Control, Engineering/
Physical Plant, Human Resources, and
Administration. Each of these groups, in
turn, should ensure the representation
of front-line workers who have deep
understandings of both operational
constraints and opportunities. Critical
40
CASE STUDY: Spaulding Rehabilitation Hospital, Boston, MA

In 2005, Partners HealthCare purchased a contaminated brownfield parcel of land in the Charlestown Navy Yard to replace their Spaulding
rehabilitation facility. The site is on the promontory where the Little Mystic Channel meets Boston Harbor and is at virtual sea level. When
Hurricane Katrina devastated the health care infrastructure in the Gulf region, Partners recognized their potential vulnerability and created a set
of voluntary best-practice requirements for the new Spaulding Rehabilitation Hospital, which opened in 2013. This facility is the first building on
the Boston waterfront to design for projected sea level rise.
Key decisions included:
• Placing the First Floor elevation 30” above the projected 500-year flood elevation, while maintaining universal access for rehabilitation
patients
• Placing all critical patient care functions above the first floor
• Ensuring a high performance envelope, including triple-glazed windows and exterior shading, to improve thermal performance and prevent
low interior temperatures/freezing if heating is lost in winter months or overheating if cooling or ventilation is inoperable in summer months
• Incorporating key-operable windows in patient rooms, so that if the building cooling or ventilation system is inoperable, indoor overheating
can be avoided in summer months and patients can shelter-in- place (after Katrina, indoor temperatures in sealed hospitals exceeded 100
degrees, which prompted staff to break windows with furniture in order to provide ventilation)
• Placing all critical mechanical/electrical infrastructure on the roof and above flood elevations,
to minimize possibility of interruption
• Implementing gas-fired on-site cogeneration (CHP) to provide efficiency and redundancy for
power generation in the event of grid loss or diesel generator issues (CHP infrastructure is on
the roof, as are emergency diesel generators)
• Implementing extensive green roofs to mitigate stormwater discharge during heavy rainfalls
None of these measures, which collectively added between .3 and .5 percent to the initial
cost of construction, was mandated by federal, state, or local codes. In fact, Partners had to
overcome substantial utility resistance to locating cogeneration and major electrical switchgear
above the ground floor. In addition to providing enhanced resilience to extreme weather,
the building envelope and energy conservation measures reduce energy demand in normal
operation, in turn reducing carbon emissions. The building uses an estimated 30% less energy
than a conventional building. The ongoing operational savings from these envelope and system
measures more than offset the additional capital investment. Figure 11: Spaulding Rehabilitation
Hospital, completed in 2013 on
the Boston waterfront, includes
such resilience features as an
elevated first floor and roof-mounted
electromechanical infrastructure.
41
Element 2: Land Use Planning, construction can allow a facility to remain equally appropriate for retrofitting and
Building Design, and Regulation operational throughout extreme weather new development. The case study of
events (see case study on page 45). Texas Medical Center (Element 5, below)
Land use decision-making affects the demonstrates how even the largest urban
resilience of a campus or building. Finally, there is the matter of how, and medical campus in the U.S. can radically
Several generations of land use planning under what set of regulations, buildings transform its campus land use approach
decisions have severely disrupted have been constructed. Recent extreme (and partner with its broader community)
a range of ecosystem services and weather events suggest that relying to better manage extreme rainfall.
natural resilience to extreme weather on historical baselines will not ensure
events. For example, infilling of wetlands future building performance, especially
in coastal regions and the loss of for critical buildings such as hospitals. The U.S. Green Building Council’s
protective dunes have increased coastal Considering extreme weather hazards LEED® Rating System (www.usgbc.org)
storm surge vulnerabilities. Likewise, in conjunction with building type and and the Sustainable Sites Initiative
development along the Mississippi potential building vulnerabilities will help (www.sustainablesites.org), an
River, with its complex system of levees health care organizations improve their interdisciplinary effort by the American
and dikes, has disrupted the natural climate resilience. Society of Landscape Architects; the
flows and functions of floodplains. It is Lady Bird Johnson Wildflower Center
therefore imperative to understand the Land Use, Siting, and Landscape at The University of Texas at Austin;
broader land use context within which a
Sustainable design has radically and the United States Botanic Garden,
building or campus is located or being
transformed approaches to land use Washington, DC, provide voluntary
planned, and to consider the ways that
at the individual site and building level, national guidelines and performance
land use decision making can mitigate or
producing approaches that will likely benchmarks for sustainable land
exacerbate severe weather impacts.
improve resilience to extreme weather design and Construction practices.
In some regions of the U.S., local events. Many of these strategies are
regulation prohibits locating critical
medical facilities inside the 100-year
or 500-year flood zones. Other regions
allow development inside floodplains,
with a range of requirements for location.
For example, Spaulding Rehabilitation
Hospital was just completed on the
Boston waterfront; the state of Florida,
on the other hand, prohibits new
hospital construction in the 100-year
surge and inundation area. Residential
health care uses (particularly nursing
homes and assisted living facilities)
have grown rapidly in vulnerable coastal
regions, and local land use regulations
are increasingly mandating improved
resilience measures (e.g., emergency
power, higher design flood elevations) for
such facilities. Shorefront Rehabilitation
Center, in Brooklyn, New York,
demonstrates how conducting a risk Figure 12: Examples of how climate data can be used to inform land use and
assessment and employing more resilient transportation decision making (Larsen et al., 2011).
42
Hospital and long term care campuses

are often standalone facilities,
surrounded by surface parking and
CASE STUDY: Boulder Community Foothills Hospital,
located away from other retail and Boulder, CO
commercial services. Collocation of Located on the east side of Boulder, Colorado, the Boulder Community Foothills Hospital
health care facilities with additional retail (BCFH) is framed by the Flatirons, the first of the Rocky Mountains rising steeply above
or service settings, such as food service, the Front Range plains to the east. The facility, completed in 2003 but not fully occupied
retail pharmacies, and laundromats, until 2004, was the first LEED-certified hospital building in the U.S. It includes a range of
can improve long-term resilience by
innovative site and land use strategies.
providing auxiliary services to personnel
and the public during extended weather Early in the planning process for the facility, a search for suitable sites revealed that few
disruptions. Hospitals within walking vacant parcels of sufficient size (16-17 acres) were available within the city limits. However,
distances of residential neighborhoods a 39-acre parcel in the county was just over the city boundary and could be annexed into
may also encourage essential personnel the city. The site was entirely within the floodplain of Boulder Creek and a tributary, Bear
to live nearby (see Element 4). Canyon Creek, which merge on the property. Two reservoirs are located upstream: Barker
Dam on Boulder Creek and Grosse Reservoir on Bear Canyon Creek.
Orientation of the building can affect
the thermal and wind performance of
the envelope. Orienting buildings to
time, less frequent, even if more intense, Because of anticipated high
minimize thermal loads, particularly
rain events will place additional strain on groundwater and the fact that the below-
heat loads, will reduce the probability
landscape irrigation sources. In such grade areas are constructed into fill that
of overheating if a building’s air
conditions, it will become increasingly is subject to saturation during flooding,
conditioning systems fail. In climates
important to consider using native, all below-grade areas are designed
dominated by heat, exterior solar
drought tolerant plant species and and certified as floodproofed spaces.
shading devices can reduce extremes
harvesting and storing rainwater on site, Floodproofing extends two feet above
of solar gain. In such climates,
whether through specific landscape the 100-year flood elevation, and one
consideration of covered parking also
features or rainwater cistern systems. foot above the 500-year flood elevation.
becomes more critical.
The City of Boulder required that The City of Boulder has experienced
Research suggests that changes in plant
the design of the hospital meet the severe flooding of Boulder Creek on
hardiness zones may occur as a result of
standards of the city’s building code numerous occasions, and has been
increasing temperatures, more intense
and floodplain management ordinance, actively undertaking efforts to clear
and frequent heat and precipitation
which resulted in several measures portions of the floodplain for use as a
events, and longer periods between
to provide a higher level of protection greenway and public open space.
storm events. Models suggest a
against flood hazards than is required Prompted by concern about how
systematic habitat shift toward the poles
for buildings that do not provide effectively it could respond to serious
(Parmesan & Yohe, 2003). In areas
critical services. The 17 acres of the flooding, in early 2006 the city
subject to coastal flooding, landscapes
site that were needed for the campus, developed a scenario that involved
must be able to tolerate saltwater
entirely outside of the designated catastrophic flooding, bridge failures,
inundation. Following Superstorm Sandy,
floodway, were proposed to be filled and numerous flooded buildings and
New York City enacted new plant
to one foot above the 100-year flood neighborhoods. The drill was organized
species requirements (Building Resiliency
elevation. The remaining 22 acres were with partners throughout the area,
Task Force [BRTF], 2013). Changes to
placed in conservation easement. including the Boulder Community
precipitation patterns, length of seasons,
Engineering analyses were performed Foothills Hospital and other health care
and average ambient temperatures will
to demonstrate that no increase in flood facilities (FEMA, 2011). Clearly, the
be determining factors in climate-
elevations would result. hospital’s close collaboration with the
adapted landscape design. At the same
43
the DFE. At a minimum, a hospital’s

access road should be at least as high
as the adjacent public road so that the
same level of access is provided during
flooding (FEMA, 2011).
The following strategies highlight

emergent practices in mitigating and
adapting transportation vulnerabilities:
• Enhance data on local contextual
factors: understand local
transportation conditions and
context, infrastructure age, and
impacts from past weather events.
• Assess access roads and building
evacuation routes for extreme
weather vulnerabilities, and consider
whether downed trees floods, or
blocked culverts will affect road use
and site access.
• Develop extreme weather impact
Figure 13: The site plan for Boulder Community Hospital, a 39-acre parcel located entirely scenarios based on recent events,
within the Boulder Creek floodplain, elevates the developed area and includes 22 acres of forecasts, and local conditions to
conservation easement. identify vulnerabilities and cascading
effects.
personnel, supplies and the injured
City of Boulder and broader community • Develop or maintain access
during extended periods of floodwater
resulted in the integration of these redundancies (ensure site or campus
inundation. These new hospitals include
advanced measures during the early access from at least two roads).
boat docks and launches at upper levels.
stages of design, when resilience could Collectively, these represent an emergent • Understand evacuation routes and
be integrated at little to no additional set of considerations both during and procedures when locating helipads,
cost to the project. after extreme weather events. ambulance drop-off zones, and other
vital points of access.
Transportation and Site Access Hospital campuses have been • Develop carpool and vanpool
significantly hampered by travel systems for “normal” operation that
The decision to evacuate UT Medical
disruptions and restrictions following can be activated following extreme
Branch on Galveston Island (see the
extreme weather events. Access to weather emergencies.
case study on page 21) was based
gasoline, restricted access on bridges,
primarily on the vulnerability of the
and disruptions to major public transit Building Regulations
bridge to the mainland. That bridge, if
systems have caused lingering access For existing health care campuses, it
damaged, would not have been available
issues for hospitals. is important to understand the codes
for later evacuation of patients, not to
mention the ongoing flow of supplies, that were in place when buildings were
In flood-prone areas, some state or local constructed, while for new campuses,
staff, and the functioning of the campus
regulatory authorities require that access it is imperative to compare future
for an extended period of time. New
roads be designed so that the driving climate risk projections to current local
hospital construction along the Gulf
surface is at the design flood elevation codes. Most states have adopted
Coast anticipates the need to receive
(DFE) or no more than 1 to 2 feet below
44
model national building codes to

govern the construction of buildings,
sometimes modifying them to reflect
CASE STUDY: Shorefront Rehabilitation Center,
local considerations. In general, building Brooklyn, NY
codes address minimum standards of
Built in 1994, the Shorefront Center for Rehabilitation and Nursing Care was designed to
construction, based on accumulated
experience. For example, prior to 1970, comply with building code requirements for flood-resistant construction due to its proximity
buildings in the United States were to the ocean. Built to exceed the 500-year flood elevation by three feet, the entire facility
not constructed with enhanced wind is elevated nearly 30 feet above ground, with parking spaces located below. All of the
resistance for tornadoes or hurricanes. building’s systems and equipment are also elevated and thus protected from floodwaters.
Modeling building performance in high The emergency power supply is furnished with enough capacity to run medical equipment,
winds was either prohibitively expensive elevators, and heating, ventilation, and air conditioning (HVAC) systems to ensure the facility
or impossible. Impact-resistant glazing can continue to operate during power outages. Furthermore, the elevated first floor houses
did not exist. only the lobby and other support services. Community and administrative space is located
on the second floor, and residents’ and patients’ rooms start on the third.
Since the 1970s, coastal cities have
benefitted from better tracking of During Sandy, the building functioned
ocean wind speeds and their likely as planned. At the peak of the storm,
effects on development. Resulting floodwaters filled the parking area and
building regulations mandate façade reached the lobby door but did not enter
performance to particular wind the building. Emergency power generators
velocities. High wind strategies are remained safe and supplied backup power
employed in areas where wind velocities for four days while area-wide power was
can exceed 90 miles per hour: hurricane out. The nursing home’s emergency plans
and tornado-prone regions often
for food and medical supplies allowed staff
require hardening façade performance
and patients to shelter in place despite
to higher wind speeds. Floodplain
limited transportation for incoming supplies
mapping, updated in the 1970s and
1980s, resulted in local building code
Shorefront was not only able to provide
regulations mandating the hardening continuous care to its residents during and
after Sandy, it also assisted people from Figure 14: Shorefront Rehabilitation
of facilities in floodplains. Some states Center, Brooklyn, NY, functioned as
have modified their local codes to the local community who sought food and
planned during and after Superstorm
respond to particulars of extreme shelter (SIRR, p 149). Sandy. The structure was designed to
weather, enacting substantial provisions accommodate storm surge at its base
for both wind-resistance and flood- levels; all critical infrastructure is above
proofing of critical buildings. flood elevations.
Newer local regulations have moved

toward performance-based codes rather
than prescriptive requirements—for
example, designating that a building
enclosure must be resistant to 200 mile
per hour winds without prescribing
the precise strategies to achieve this
requirement. This regulatory approach
places more responsibility on building
owners and their design professionals
45
to determine how such performance

requirements can be achieved. Additional guidance on improving wind
and flood performance of building
Building Envelope and Vertical façades and envelopes is found in
Transportation Systems FEMA’s publication #577, Design
FEMA publishes its findings on building Guide for Improving Hospital Safety in
vulnerabilities and failures from every Earthquakes, Floods, and High Winds:
major extreme weather disaster as a Providing Protection to People and
series of Mitigation Assessment Team Buildings. This document includes
(MAT) reports. Based on these and useful checklists for building structural
other investigations, it has developed and non-structural vulnerabilities.
guidance on best practices for building
envelopes to withstand hurricanes, Green Building and Climate Resilience:
tornadoes, flooding, and earthquakes, Understanding impacts and preparing
including checklists that improve for Changing Conditions, published
assessment processes. Because by the University of Michigan and
building enclosure failures have been U.S. Green Building Council, includes
a common occurrence in high wind a range of strategies for retrofitting
and flooding events, understanding the envelopes for improved performance.
vulnerabilities of existing enclosures
and developing a plan to harden those
enclosures is an important aspect of
climate resilience. Vertical transportation systems are
also vulnerable to flooding and wind
Key practices for addressing wind damage. High winds can damage
vulnerabilities include: rooftop penthouses containing elevator
• Properly anchoring roofing and machine rooms; elevator pits are prone
rooftop equipment in high wind to flooding, which disables elevators.
areas (in many instances, roofs and While elevators are included as part of
equipment are blown off, leading to the emergency power systems, physical
water penetration and evacuation of damage may render them useless in
buildings) emergencies. During and after both
• Removing all items that may become Katrina and Sandy, patient evacuation
projectiles, e.g., loose furniture and was conducted via stairwells. NYU
equipment, ballasted (gravel) roofs Langone Medical Center, New York, was
within 1500 feet of critical buildings designing a new public elevator system
• Designing enclosures to resist for a major bed tower prior to Sandy;
high wind, including wind and these elevators do not extend to below
impact resistant glazing and façade grade floors, reducing the possibility for
construction flooding (Schwabacher, 2014). Mercy
Hospital, Joplin has designed multiple
elevator banks to minimize the risk of
wind damage disabling all elevators.
46
CASE STUDY: Louisiana Heart Hospital, Lacombe, LA

Prudent decision-making during the design and construction of Louisiana Heart Hospital contributed to its ability to withstand Hurricane Katrina.
Opened in February 2003, the hospital is a 58-bed specialty care facility. The non- flood zone property was selected for its convenient location
above the storm surge projection. Wynn Searle, the Vice President of Operations/Hospital Development at Medcath, Incorporated, stated that “its
location dictated a wind- resistant design per code requirements, including common engineering safety features.”
A wetland survey revealed the need for extensive site preparation, including placing more than $1 million worth of sand to compress the
swamp-like soil. Safety measures included the installation of impact-resistant windows that meet the missile impact test created for hurricane-
prone areas by Miami-Dade County, Florida. These reinforced windows are designed to sustain the force of winds of 130 to 140 mph. According
to Mr. Searle, “measures were taken to attach the roof membrane to meet a certain ‘wind uplift requirement’ (determined by their insurance
company and testing lab) to preclude uplift from significant wind storms.”
One advantage of these construction techniques is lower flood insurance premiums. According to hospital officials, these premiums would have
been considerably higher if they had not used such hurricane-resistant methods and materials. There were additional costs associated with the
damage prevention measures, but the minimal damage sustained by the hospital and the ability to continue to operate demonstrated their cost
effectiveness for the organization.
An independent water-treatment plant for domestic water supply and fire protection, and a 1,700-foot well that was drilled during construction
allowed the facility to function without municipal water after the disaster. During Katrina, the
hospital’s two large generators engaged when electrical power failed. Additional diesel fuel was
ordered as the storm approached, enabling the hospital to run the air-conditioning units and
continue dialysis treatments, cardiac catheterization lab procedures, and surgeries. The protocol
for back-up diesel fuel has since been addressed and cylinders have been purchased to hold an
additional 1,800 gallons of fuel on site.
During Katrina, all entrances to the hospital except the emergency entrance were blockaded and
sandbagged. No flooding occurred; mechanical roof screen panels bolted to a support system
on the roof caused the only damage to the hospital. The hurricane winds played havoc with
the panels, slashing parts of the hospital roof and causing some leaks. Flying debris damaged
several cars in the parking lot. The hospital remained operational (United States Department of
Homeland Security, 2012).
Figure 15: Louisiana Heart Hospital,

designed to withstand high winds,
successfully operated through
Hurricane Katrina
47
Passive Survivability
CASE STUDY: Mercy Hospital, Joplin, MO A critical element of sheltering in place
during extended power outages is
Within three months following the destruction of St. Johns Regional Hospital in Joplin, MO, the potential for loss of mechanical
a temporary modular building replacement was erected on the former hospital parking lot. ventilation, air conditioning and
At the same time, an accelerated design and planning process for the replacement facility humidification or dehumidification
began. The building, scheduled for completion in early 2015, has incorporated a number of functions. Clearly, a focus of residential
specific “hardening” features to respond to tornado risk. health care resilience planning should be
extending critical conditioning system
First, critical care areas—intensive care and neonatal intensive care—are outfitted with performance, even if conditioning
250 mph impact resistant windows; the ED, bridge, and clinic “safe rooms” are outfitted power is provided through external
with 140 mph windows. The central utility plant (CUP) is located in a separate, standalone generator hookup capabilities. At the
“hardened” building (as opposed to a pre-engineered lightweight metal structure, a same time, secondary or redundant
current common practice); services are connected through an underground tunnel. Critical passive solutions should be considered
infrastructure is placed below grade in for various reasons: unless very large,
the CUP. Specific façade elements include generators are rarely able to provide
concrete roof decks (versus metal deck), air conditioning or general lighting.
precast siding (in lieu of lightweight Exterior Increasing attention is on enhancing
Insulation and Finishing Systems (EIFS)), building envelope design to reduce solar
and safety windows. A reinforced core and gain or heat loss to extend habitable
stairwells provide additional safe haven temperatures for longer periods of time.
Passive survivability measures should
areas within the building. An independent
be carefully considered in conjunction
water service is included.
with multiple hazard assessment: some
measures may be inappropriate for
chemical or bio-terrorism events.
Strategies to extend passive survivability

include implementation of building
Figure 16: The new Mercy Hospital, façade design measures ranging from
Joplin, Kansas is being constructed to enhanced insulation, roof overhangs,
resist high winds. or fixed solar shading devices, to the
use of operable windows, which permit
enhanced thermal comfort. While
operable windows are not generally used
in hospitals, they may be appropriate
for other residential health care settings,
such as nursing homes, rehabilitation
facilities, and the like. They may also
be included to mitigate overheating in
hospital buildings in the event a building
remains occupied following total
system failure, as a safety measure for
patients awaiting evacuation following
a catastrophic event. The experience
of staff breaking windows in hospitals
48
Infrastructure protection and resilience is

a key element of health care facility oper-
CASE STUDY: Washington State Veterans Home, ation through extreme weather events. In
Retsil, WA Hurricane Sandy, the failure of both grid
power and emergency generators forced
When the Washington State Department of Veterans Affairs began planning for a new
hospital evacuations. While generators
skilled nursing facility, residents and
were located above flood elevations,
staff were actively engaged to define the
critical infrastructure components—fuel
qualities of the best skilled nursing care pumps, fuel tanks, electrical switch-
environment for veterans. When the project gear—were not. This section examines
team asked residents to describe their energy, water, and waste infrastructure,
ideal environment, they identified many as well as fire protection and communi-
sustainable design solutions—operable cation infrastructure; all of these com-
windows, daylight, and access to the ponents are necessary to safely shelter
outdoors. Recognizing the Sinclair Inlet, in place during and after an extreme
with its mild microclimate and sea breezes, weather event.
as a unique, manageable natural resource,
the design features a naturally ventilated Energy and Utility Infrastructure:
cooling solution—there is no mechanical power and thermal energy
cooling installed in the facility (Guenther & Particular care must be exercised with
Vittori, 2008; Younger, 2007). Figure 17: Washington State Veterans’ energy and utility infrastructure in high
Home orients resident wings to wind and flood hazard zones. Utilities
maximize passive cooling and prevailing include all systems, equipment, and
winds, and includes engineered natural fixtures, including mechanical, electrical,
ventilation to replace air conditioning.
plumbing, heating, ventilating, and
air conditioning. Utility systems and
equipment are best protected when
elevated above the DFE (plus freeboard,
if required to account for sea level
rise projections). Equipment that is
following Katrina as indoor temperatures Element 3: Infrastructure required for emergency functioning
exceeded 100 degrees suggests that Protection and Resilience during or immediately after an event,
window operability in emergencies may
such as emergency generators and fuel
be prudent. Spaulding Rehabilitation Katrina showed that hospitals depend heavily
tanks, should be installed well above
Hospital, Boston, MA, includes key- on citywide infrastructure— electrical the DFE. In some cases, equipment
operable windows in resident rooms as
power, communications, water, security, and can be located inside protective flood-
an enhanced resilience measure, while
transportation—that can be disrupted by an proofed enclosures, although it must
the Washington State Veterans Home in
be recognized that if flooding exceeds
Retsil, Washington, includes them as a area-wide disaster ... it was the combined
the design level of the enclosure, the
basic design feature. loss of essential infrastructure and utilities equipment may be adversely affected—
that put hospitals and their patients into such Bellevue Hospital was evacuated after a
perilous circumstances. Disaster planning fuel pump, protected behind a submarine
door for more than 48 hours, failed.
after Katrina for hospitals must incorporate
the possible loss of essential infrastructure Plumbing conduits, water supply lines,
(Gray & Hebert, 2006). gas lines, and electric cables that
49
must extend below the DFE should a health care savings financial analysis offering load sharing advantages and,
be located, anchored, and protected calculator, are available (EPA, 2014). potentially, improved reliability. Texas
to resist the effects of flooding. At UT Medical Center is one such an entity.
Medical Branch, Galveston Island,
For new buildings, the Targeting 100!
elevated steam and power lines were Power Reliability and Emergency
research completed by a consortium
severely damaged by wind; in the Power
led by the University of Washington
reconstruction, they were securely
provides guidance for reducing hospital The vast majority of hospitals rely on
buried in a floodproofed tunnel system.
energy intensity by 60% below current municipal utility grids for electrical ser-
By contrast, the Texas Medical Center,
average consumption. The ASHRAE vice, with on-site boiler and chiller plants
Houston, where wind is less of a threat
providing thermal energy needs at either
than severe flooding, has raised its utility Advanced Energy Design Guides
an individual building level or, increas-
infrastructure in secure above grade include a compendium of strategies
ingly, through an on-site freestanding
intra-building walkway structures. for large hospitals, small hospitals
Central Utility Plant (CUP). Hospitals are
and medical office buildings to reduce
required to include emergency power
Additional guidance on improving the energy demand by 30 to 50%. generation that activates within 10 sec-
flood resistance of utility installations onds of loss of grid power, with sufficient
in existing buildings is found in fuel for 96 hours of operation. Emergency
FEMA publication #348, Protecting District Thermal Energy Systems power systems are generally comprised
Building Utilities From Flood Damage: of on-site electrical generators, powered
District energy systems distribute steam,
Principles and Practices for the Design by reserves of diesel fuel, and are sized
hot water and/or chilled water from
to cover critical medical equipment and
and Construction of Flood Resistant a central plant to individual buildings
building system loads, including, at a
Building Utility Systems. through a network of pipes. The
minimum, building ventilation (not condi-
International District Energy Association
tioning), vertical transportation, and key
estimates that there are more than 5,800
support service requirements. Diesel gen-
district energy systems in the U.S.,
Energy Efficiency primarily serving urban downtowns, erator systems are required to be tested
university or hospital complexes, or monthly, and once every three years
Energy efficiency measures may be
military bases (International District under full load conditions for 4 hours.
regarded as a first step in resilience
planning. The less energy required to Energy Association [IDEA], 2014). By
Historically, the use of on-site backup
operate a health care facility, the longer combining many thermal loads, district
generators is related to grid reliability; the
that facility can remain operational on energy provides economies of scale to
more reliable the grid, the less generators
a given capacity of reserve fossil fuel. effectively implement high efficiency
are used. However, in large urban areas
Energy efficiency retrofit measures in fossil fuel and renewable energy
hospital owners increasingly utilize diesel
existing hospitals can routinely save technologies. Large, co-located, multi-
owner health care campuses are rapidly backup generators as a form of peak
20-25% of energy demand; in new load reduction during peak electrical
buildings, high performance systems coalescing into “medical campuses,”
often with an independent legal and demand in hot summer months. Because
can reduce the average energy backup generators are generally seldom
governance entity as property and
consumption by 40-50% or more below used, they can encounter problems in an
operations manager. In this arrangement,
national average (Guenther & Vittori, actual emergency. During the extended
individual academic, research, and
2013). Hospitals and other buildings can Northeast blackout in 2003, nearly half of
health care entities are assigning
benchmark their energy performance New York City’s 58 hospitals’ emergency
parking, traffic, and site management
using EPA’s ENERGY STAR Portfolio generator systems encountered reliability
functions to a larger campus entity.
Manager, a free online tool used by to problems during the extended use period
Often, the medical campus includes a
measure and track energy consumption (Hampson, Bourgeois, Dillingham, &
district energy system supplying thermal
as well as greenhouse gas emissions. Panzarella, 2013).
energy and power to the campus,
Other free tools and resources, including
50
As backup generator systems expand in

capacity to add air conditioning or cover
ever-expanding hospital campuses, the
CASE STUDY: Greenwich Hospital, Greenwich, CT
emissions associated with their routine The Greenwich Hospital is a 175-bed, 500,000 square foot ENERGY STAR certified (2011,
testing and use during peak loads may 2010) medical center located in Greenwich, CT. Its CHP system, installed in 2008, consists
approach EPA allowable limits under of two 1,250 kW natural gas-fired reciprocating engines. The hospital also has a 2,000
the Clean Air Act. Diesel generators are kW backup generator. The system typically runs 24 hours a day, 7 days a week, except for
noisy; the testing and use in or near routine maintenance. The hospital uses the thermal output of the system for hot water and
residential neighborhoods is at best space heating. The hospital also participates in a demand response program with EnerNOC,
a nuisance, at worst a health hazard. which calls on the hospital to go off the grid for stabilization purposes if the grid is in
Hence, hospitals have begun to search danger of an outage. The hospital is compensated at a rate of $30/kW when called upon
for more reliable normal and extended
to disconnect from the grid. This provides another financial revenue stream from the CHP
emergency power generation solutions.
system, beyond the energy operating savings.
Combined Heat and Power (CHP) The area surrounding Greenwich Hospital lost power due to Superstorm Sandy for
As the scale of medical campuses approximately 7 days. When the hospital lost grid power, it went down for about 7 seconds
increases, hospital requirements before the backup generators kicked in and power was restored. The transition from using
for more reliable on-site electrical grid power to operating solely on the CHP system went as planned, with the CHP system
generating systems have increased; shutting down and restarting in island
many are investing in grid-connected mode, while power was supplied to the
combined heat and power systems hospital by backup generators. The whole
(CHP) to generate power on-site transition process took approximately 5
and reduce reliance on municipal minutes. Due to its CHP system, Greenwich
grid infrastructure. The Veterans Hospital was able to continue normal
Administration, for example, installs operations throughout the storm. The
campus CHP on all new VA medical hospital admitted 20 additional patients
center campuses. While these systems during the outage period, raising the patient
require a longer time to safely shut
count from 136 to 156. In addition, 150
down, disconnect from municipal grid
extra staff stayed overnight to ensure the
infrastructure, and safely resume in
hospital remained fully functioning (ORNL,
island mode—10 minutes or more—
2013).
their more reliable uninterrupted
operation through extended periods of Figure 18: The Greenwich Hospital’s
grid disruption is proving to be beneficial on-site combined heat and power
for long-range resilience. In some system operated without incident
areas of the country, utility regulations throughout the 7-day loss of utility
restrict their application in emergency services following Superstorm Sandy.
situations. Technical challenges inherent
in 10-second power resumption means
that these systems still require diesel
generator supplemental power, even if
only for the switchover period.
CHP systems are a highly efficient

form of distributed generation, typically
designed to power a single large
51
building, campus, or group of facilities. steady supply of fuel” (Hampson, Bourgeois, Renewable Energy
In the context of critical infrastructure Dillingham & Panzarella, 2013). On-site renewable energy systems
applications, these CHP systems
provide enhanced resilience. Many
are comprised of on-site electrical For many hospital owners, this shift
U.S. hospitals are installing wind or
generators (primarily fueled with natural to CHP is significantly contributing
solar energy systems for both thermal
gas) that achieve high efficiency by to greenhouse gas reduction and is
energy (domestic hot water heating)
capturing heat, a byproduct of electricity a cornerstone of voluntary climate
and electric power generation. To date,
production that would otherwise be commitments. Partners HealthCare,
the performance of renewable energy
wasted. The captured heat can be for example, is implementing CHP its
systems in extreme weather events
used to provide steam or hot water to 11-hospital system by 2020 as part
has been good, with limited damage
the facility for space heating, cooling, of its strategy to meet the initial 50%
to such systems from high winds or
or other processes. Capturing and GHG reduction target mandated by
flooding. Some hospitals have benefitted
using the waste heat allows CHP the Massachusetts Global Warming
from Power Purchase Agreement
systems to reach fuel efficiencies of Solutions Act (Guenther & Vittori, 2013).
(PPA) installations on parking lots and
up to 80%, compared with about 45% The damage caused by hurricanes along
roofs. Third party power providers who
for conventional separate heat and the Texas and Louisiana Gulf Coast in
continue to own the equipment fund
power. This is both environmentally the past several years have propelled
these arrangements; hospitals provide
and economically advantageous. CHP the adoption of critical infrastructure
the site and purchase the power.
systems can use the existing, centralized policies in these two states. Additionally,
electricity grid as a backup source to due in part to the Northeast blackout
meet peak electricity needs and provide in 2003, storm events, security threats, The Department of Energy National
power when the CHP system is down for and other concerns, New York State has
Renewable Energy Lab (NREL) provides
maintenance or in an emergency outage. also been a strong proponent of CHP at
critical infrastructure facilities. technical guidance and resources
If the electricity grid is impaired, the CHP for renewable energy applications in
system continues to operate in “island health care settings. The Renewable
mode,” ensuring an uninterrupted Additional guidance on CHP can be Resource Data Center (RReDC) provides
supply of electricity to the host facility,
found in the U.S. Department of Energy access to an extensive collection of
dependent upon an uninterrupted power
and EPA Guide to Using Combined Heat renewable energy resource data, maps,
supply. During and after Superstorm
and Power for Enhancing Reliability and and tools. NREL’s energy disaster
Sandy, combined heat and power
Resiliency in Buildings and Combined
(CHP) enabled a number of critical recovery program offers a broad range
infrastructure and other facilities to Heat and Power: Enabling Resilient
of services, including whole-community
continue their operations when the Energy Infrastructure for Critical
Facilities, by ICF International, prepared energy planning, on-site technical
electric grid went down (see Greenwich
Hospital Case Study below). Oak Ridge for Oak Ridge National Laboratory assistance, energy-efficient design
National Laboratory reports: (Hampson, Bourgeois, Dillingham & and rebuilding strategies. It assisted
Panzarella, 2013). Health Care Without Greensburg, KN, and Kiowa County
“In general, a CHP system that runs
Harm has teamed with the Boston Memorial Hospital in the rebuilding of a
consistently throughout the year is more
Green Ribbon Commission to publish clean energy community.
reliable in an emergency than a backup Powering the Future of Health Care:
generator system that only runs during Financial and operational Resilience—
emergencies. Because it is relied upon daily Combined Heat and Power Guide for Gundersen Health System (Wisconsin,
for needed energy services, a CHP system is Massachusetts Hospital Decision Minnesota, Iowa) was the first U.S.
Makers (Benden, Veilleux et.al., 2013). health system to target (2008) and
also more likely to be properly maintained,
reach energy independence (2014).
operated by trained staff, and to have a
52
The system, consisting of more than 60 Water supply interruptions can result • A hospital in Texas lost water service
locations, offset its energy consumption from water main breaks (extreme cold for 48 hours due to an ice storm that
through a diverse, locally sourced, or age) or flooding or high wind damage caused a citywide power outage that
portfolio of projects. They include: to municipal water infrastructure. In included the water treatment plant.
four wind turbines, two dairy digester other instances, water pump failures • A nursing home in Florida lost its
projects, a landfill gas to energy project, (due to flooding or lack of power) can water service for more than 48 hours
a bio-mass boiler, geothermal wells, compromise water availability in upper as a result of Hurricane Ivan.
and solar projects (Gundersen Health floors of buildings. A water main break
System, 2014; Guenther & Vittori, 2013). in Boston in May 2010 interrupted water
supply to Boston’s hospitals, some of The Centers for Disease Control and
Water Use and Supply
which succeeded in rerouting pipes for Prevention and American Water Works
Consistent access to a reliable potable alternate sourcing while others survived Association have an Emergency Water
water supply is another key element on bottled water. Scott Lillibridge, Supply Planning Guide for Hospitals
of resilience. The Joint Commission professor of epidemiology at Texas A&M and Healthcare Facilities to assist
requires hospitals to address the University, north of Galveston, notes how health care facilities in meeting
provision of water as part of their close the hospitals of Houston came to
Emergency Operations Plan (EOP),
requirements of EOP’s required by
collapse in the aftermath of Hurricane Ike, CMS and Joint Commission, estimating
but does not require a specific reserve
when the storm disabled the city’s water water demands, and preparing options
capacity. The Center for Medicare and
pumping systems: “The lack of water
Medicaid Services (CMS) Conditions for for meeting demands during extended
pressure to hospitals in Houston in the
Participation/Conditions for Coverage supply interruptions. The CDC, NOAA
immediate post-disaster period almost
(42 CFR 482.41) also requires that health and EPA have a resource for public
resulted in one of the largest patient
care facilities make provisions in their health professionals preparing for
evacuations in history. Without water
preparedness plans for situations in drought: When Every Drop Counts:
for toilets, laundry and food service,
which water supply interruptions may Protecting Public Health During
the hospitals were down to their last 24
occur. There is, however, no standard
hours of patient services.” There was not Drought Conditions.
for the quantity of reserve or back-
up water that is required; it varies by sufficient bed capacity in the entire state
state and region. The Emergency Water to receive evacuees from Texas Medical
Supply Planning Guide for Hospitals and Center (World Health Organization, 2009). One of the key challenges with fixed
Health Care Facilities (see sidebar on quantity emergency water supplies is
Some examples of hospital water supply
right) can assist hospitals in planning accurately estimating demand—clearly,
interruptions at health care facilities
for a disruption of water; it suggests the lower the potable water demand, the
(CDC 2011):
that health care facilities maintain longer a given supply of water will last.
enough water for 8 hours of emergency • A hospital in Florida lost water service Many hospitals and nursing homes have
distribution. The state of California for 5 hours due to a nearby water not historically tracked water usage;
requires hospitals to keep a minimum main break. there are few reliable benchmarks for
of 96 hours of potable water available • A hospital in Nevada lost water water consumption. ENERGY STAR
should the municipal water supply fail service for 12 hours because of a and EPA WaterSense programs show
in a seismic event. Hospitals that plan break in its main supply line. that only 2% of program participants
for alternative supplies use a storage • A hospital in West Virginia lost service are hospitals and 2% are medical
tank, a large supply of bottled water, or a office buildings. However, hospitals
for 12 hours and 30 hours during two
combination of these approaches. Other demonstrate the widest range of water
separate incidents because of nearby
hospitals and long-term care facilities use intensity, from negligible use to more
water main breaks.
have independent, secondary wells than 150 gallons per square foot per
capable of supplying building needs if • A hospital in Mississippi lost service
year (EPA, 2012). The American Society
the municipal supply is compromised. for 18 hours as a result of Hurricane
of Plumbing Engineers’ (ASPE’s) out-
Katrina.
53
of-print publication, High-Rise Plumbing Independent Water Services consumption, it must be treated to
Design by Alfred Steele, P.E., CIPE, satisfy federal drinking water standards.
In order to meet the requirement for
estimates the minimum hourly flow rate In many areas of the U.S. concerned
adequate water during municipal
of domestic water for a hospital to be with long-range drought, parallel non-
disruptions, hospitals and nursing
3 gallons per bed, per hour, with an potable water distribution systems are
homes may install independent well
average daily consumption estimated being installed to enable the collection
water services. Many hospitals in
between 235 and 300 gallons per bed, and redistribution of reclaimed or
Florida have independent wells, given
excluding HVAC systems (Salfarlie, recycled “graywater.” Alternative
the high water demand associated with
2012). At the same time, because methods for using rainwater also are
cooling towers and air conditioning
health care organizations generally being developed. For example, buildings
systems during emergency conditions.
view probability of water supply are increasingly being engineered
The Wisconsin Hospital Emergency
interruption as a low risk, supplies may with the capability to collect and use
Preparedness Program provided a
be undersized for actual demand. Water rainwater for nonpotable applications
multi-phase funding opportunity to
supply resilience is improved through a (such as for flushing toilets and
allow hospitals to develop on-site wells
range of measures: water conservation, landscape irrigation).
for use during water emergencies. A
on-site water capture, and reclaimed
total of 13 hospitals completed the Extreme weather events may
water reuse systems.
installation (UMN, 2014). Kiowa County compromise local water supply quality;
Memorial Hospital and Mercy Hospital, if contamination is a risk, fixed potable
Water Conservation Joplin have a second independent water storage may be the best option.
The prospect of long-range drought and well water service; the municipal One of the key resilience benefits of
potable water stress due to changes infrastructure was destroyed in a independent water service (rather than
in rainfall patterns in many regions are tornado. In fact, the Missouri Hospital storage of a fixed water supply) is the
leading municipalities to enact stricter Association, noting that its health care potential ability for hospitals to provide
water use policies. Water conservation infrastructure was largely unprepared clean water to the larger community in
has been a focus of health care for the myriad of weather disasters that the days following a disaster. Access
sustainable design; Providence St. Peter have struck in recent years—blizzards, to potable water is a key element of
Medical Center in Olympia, WA reports floods, tornadoes— states: “Hospitals community resilience. After Katrina,
a reduction of 60% in potable water should not depend on utilities and citizens were unable to access reliable
use over a 10-year period based on a should consider redundant systems sources. Hospitals, more than any other
steady program of fixture and equipment and partnership for water and power critical building type, should place a
retrofits (Guenther & Vittori, 2013). sources” (MHA, 2012). high priority on developing independent,
high-quality reliable secondary water
Water conservation measures, such At the same time, independent water
supplies.
as low flow fixtures, reduce potable services may have reliability and quality
water demand in sanitary fixtures by challenges. Although drought most
as much as 40%. Cooling towers for commonly is defined climatologically, Reclaimed Water Reuse and
air conditioning systems can consume water supply emergencies or drought Rainwater Capture
as much as 50% of the total potable can also be exacerbated by human Municipalities in drought-prone regions
water demand; increasingly, hospitals activities. For example, even when are installing large-scale municipal
and nursing homes are shifting to precipitation is occurring at average reclaimed water systems to meet the
non-potable water sources for such rates within a specific area, urban process (non-potable) water needs of
process uses, including captured expansion and development without their communities. In hospitals, process
condensate from air handling units, regard to existing water supply and demands may aggregate to as much
municipal reclaimed water, and rainwater water system capacity can trigger a as 70% of total water use; finding
harvesting. human-induced drought. For surface reliable alternative sources of water is
water to be harvested for potable a key element of enhanced resilience
54
in a future with stressed potable water

supplies. Captured condensate (the
water generated from dehumidification
processes in air handling units) is
becoming an on-site process water
resource in more humid regions of the
country. University Health System, San
Antonio, uses the municipal reclaimed
water system for cooling tower make-
up water. Rush University Medical
Center, Chicago, uses a combination
of captured rainwater and condensate,
providing an added measure of reliability
should the municipal system be
disrupted.
The capturing of on-site rainwater as

a resource is regulated on both a state
and local level. Hospitals and medical
facilities are beginning to employ
rainwater catchment systems to provide
water for irrigation, cooling towers,
and other process loads. Southeast
Louisiana Veterans Health Care Center
in New Orleans has a 1 million gallon
rainwater cistern to capture rainwater
for cooling and process uses. At
Kiowa County Memorial Hospital in
Greensburg, KS, captured rainwater is
used to flush toilets. These solutions
significantly boost the performance of
the hospital when municipal potable
water sources are compromised.
55
CASE STUDY: Kiowa County Memorial Hospital, Greensburg, KS

On May 4, 2007, an EF-5 tornado estimated to be 1.7 miles wide with 205 mph winds struck the city of Greensburg and Kiowa County, Kansas.
Damage to Greensburg was significant, with over 90% of the structures in the community severely damaged or destroyed. FEMA activated the
Long-Term Community Recovery (LTCR) program, which integrated assistance from the State of Kansas and federal agencies focused on the
community’s long-term recovery goals. The program provided coordination of resources and planning services in support of the area’s recovery
effort; one of the key elements was a community planning process that focused on and produced a long-term community recovery plan (FEMA,
2009) to guide more resilient and climate-adapted redevelopment.
With technical assistance from the Department of Energy and the National Renewable Energy Lab, the town converted from fossil fuel electrical
generation to 100% wind-generated power. The Greensburg Wind Farm consists of 10 1.25 megawatt (MW) wind turbines that supply 12.5 MW
of renewable power to the town. That’s enough energy to power every house, business, and municipal building in Greensburg and sell power to
other Kansas municipalities. John Deere Renewable Energy built the wind farm and maintains the project (the Deere dealership was destroyed
in the tornado; this was Deere’s entry into the renewable energy market). All Greensburg buildings are constructed to meet LEED Platinum
certification criteria; while the town initially made an exception for the hospital, hospital leadership accepted the challenge to deliver a LEED
Platinum replacement building.
According to Mary Sweet, Administrator:
“The tornado not only destroyed our community and hospital—it caused a major shift in how we make decisions. In rebuilding, we learned not
to look at the initial cost only, but to look at environmental impact, long term cost savings, and sustainable and renewable resources.”
In addition to becoming the first U.S. hospital to operate with 100% renewable (carbon neutral) energy in 2011, it incorporates rainwater
harvesting and advanced water conservation strategies.
The replacement Kiowa County Hospital is the first Critical Access hospital to achieve U.S.
Green Building Council LEED-Platinum designation, and the second hospital in the U.S. to earn
this award. According to energy analysis modeling results, the new hospital is 32% more
energy efficient than an ASHRAE-compliant building of the same size and shape. Many of the
efficiency measures included in the hospital were incorporated into the Advanced Energy Design
Guide for Small Hospitals and Health Care Facilities, an energy efficiency guide developed by
DOE/NREL in collaboration with national professional societies, and a pivotal market tool for
designing small low- energy health care buildings. It includes a 50 kW on-site wind turbine to
provide approximately 40% of its total electrical load (or 100% of its base load) and uses the
Greensburg wind farm to supply the balance. It has limited on-site combustion of fossil fuel (U.S.
Department of Energy Office of Energy Efficiency and Renewable Energy, 2010; FEMA, 2009;
Guenther & Vittori, 2013).
Figure 19: The wind turbine at Kiowa
County Memorial Hospital serves
as a reminder of the commitment to
clean energy sources and enhanced
resilience.
56
Sewage/Wastewater
In flood situations, all plumbing fixtures CASE STUDY: Oregon Health and Sciences University
connected to the potable water system
may become weak points in the system
Center for Health and Healing, Portland, OR
if they allow floodwaters to contaminate The city of Portland, like many older U.S. cities, has an overburdened sewer infrastructure,
the system. Fixtures below the DFE so this LEED Platinum- certified project, which opened in 2006, included on-site sewage
should be isolated from those above treatment, with treated effluent used for toilet flushing and irrigation. The building includes
DFE. Wastewater system components a complex stack of ambulatory medical uses, including wellness, fitness, and physical
become sources of contamination therapy facilities, plus a conference center on the lower floors; outpatient clinics, imaging,
during floods. Rising floodwaters may and ambulatory surgery on the middle floors; and offices and laboratories on top.
force untreated sewage to back up
through toilets or floor drains. Specially 100% of the rainwater is harvested and used for irrigation, sewage treatment makeup
designed devices that prevent backflow water, and other process uses. The center has four separate water systems, including a
can be installed, or restrooms below blackwater system that feeds a non-potable
the DFE can be provided with overhead water supply, a conventional potable water
piping that may require specially system, and rainwater collection system
designed pumps to operate properly. that feeds the fire water cistern as well as
One of the key code measures enacted the mechanical system. One of the center’s
by New York City following Superstorm major documented impacts for subsequent
Sandy is a requirement for backflow LEED Existing Building Operation and
prevention on sewer lines in all existing
Maintenance (EBOM) certification includes
and new buildings.
saving more than 5 million gallons of
On-site wastewater treatment facilities drinkable water annually through these
provide an added measure of resilience. aggressive water strategies. (Portland
To date, the only U.S. health care facility Office of Sustainable Development, 2014;
to employ this technology remains the Guenther & Vittori, 2013)
Oregon Health and Sciences University
Center for Health and Healing in Figure 20: The Oregon Health and
Portland, OR, which uses an on-site Sciences University Center for Health
anaerobic system to treat sewage and and Healing uses four separate water
recirculates conveyance water for toilet systems to reduce reliance on both the
municipal potable water system and
flushing in a closed loop.
sewage treatment system. It captures,
treats, and recycles the building
Element 4: Protect Vital Clinical sewage conveyance water using an
Care Facilities and Functions on-site bio-reactor system.
“We expect prompt medical attention for an

injury or medical problem. This is even more
important during Mass Emergencies that
require care for large numbers of casualties.
If hospital operations are disrupted or
disabled the adverse effect of such disasters
are quickly compounded with catastrophic
results” (FEMA, 2011).
57
During emergencies, health care facilities to deliver high-quality, uninterrupted the east coast: Spaulding Rehabilitation
are responsible for more than sheltering care while cut off from transportation Hospital, Boston, for example, has no vital
residents in place—they are often called systems and re-supply infrastructure. medical or resident services on the ground
upon to deliver medical services to level; all required medical care delivery is
large numbers of injured people. It is To address these multiple needs, well above the 500-year flood level.
imperative that hospitals maintain not hospitals in flood-prone regions are
only operational infrastructure services, being planned and designed “upside- Emergency departments (EDs) present
but also vital medical care delivery down” with critical infrastructure on particular challenges. Generally,
services. Certainly, recent extreme rooftops and electromechanical these are located at grade to facilitate
weather events have demonstrated that distribution systems fed from the roof ambulance and public access. However,
ground floor emergency departments in downward. This section examines the in flood-prone areas, this often places
flood-prone areas cannot provide reliable organization of programs and buildings EDs below design flood elevation
care; likewise, expensive and necessary for uninterrupted health care service (DFE) and at risk. Many hospitals have
diagnostic imaging equipment (often delivery and surge management through effectively lost use of their EDs and
located on ground floors due to weight extreme weather events. related imaging areas both during and
and need for proximity to the ED) may for extended periods following extreme
also be destroyed or rendered unusable. Locations of Critical Programs: EDs, weather events. In coastal areas prone
Imaging to repeated surge and inundation,
Even if vital mechanical and electrical hospitals are moving their EDs to higher
There has been a significant shift in the
infrastructure is out of harm’s way, floors and constructing vehicular and
planning for hospitals in flood-prone
medical care delivery—from submerged ambulance ramps for normal operation.
regions based upon the lessons learned
departments to corridors connecting This has an additional resilience benefit:
in repeated Florida and Gulf Coast
egress and transfer pathways—can be during high water periods, the ramps
hurricanes. These lessons are moving up
severely hampered. Surges of patients facilitate boat mooring to deliver
often follow weather disasters. Tornado
survivors in Joplin flooded the one small
emergency department that remained CASE STUDY: Tampa General Hospital, Tampa, FL
open. In wildfires, hospital emergency
departments near the fire must remain
Tampa General Hospital’s emergency
operational to treat firefighters and department (ED) facilitates disaster
affected community residents. response in adverse weather events,
such as hurricanes and flooding. The
Hospitals must also prepare and ED is located on the second floor; it
stockpile supplies—more supplies than includes a vehicle ramp for ambulances
their “just in time” system inventories and a dedicated elevator for visitors and
anticipate—to remain operational walk-in patients from the ground level.
through extended transportation To accommodate patient surge, additional
and supply chain disruption. Just as
locked medical gas cabinets are located
critical, hospitals require health care
throughout the ED in waiting areas,
workers from medical professionals
conference rooms, and administrative
to environmental services workers to
deliver both direct patient care and
areas. In the case of a major event, the
Figure 21: Tampa General Hospital’s
necessary support services, such as adjacent parking garage is designed to
emergency department is on the
meal preparation and laundry. In extreme quickly become a triage area (Bosch, 2013). second floor, well above the flood surge
weather events, hospitals must house and inundation level. The vehicular
large numbers of workers, their families ramp is shown here.
and even their pets, in order to continue
58
patients, staff, and emergency supplies. routes between buildings dangerous or Personnel Accommodation,
Both Tampa General Hospital, Tampa, impassable, which can severely hinder Supplies, and Patient Surge
FL and Southeast Louisiana Veterans both ongoing shelter-in-place activities
Hospitals, long-term care, rehabilitation
Health Care Center, New Orleans, LA are or evacuation processes. Understanding
facilities—in short, all residential health
examples of this programmatic shift. the risks, and developing strategies
care facilities—require round-the- clock
to minimize them, is a key element of
staffing to remain in operation. Front-line
Evacuation Routes: Heliports and resilience planning.
health care workers include both clinical
Building Connectivity care staff—doctors and nurses—as well
Safe paths of travel between buildings are
During Katrina, continued high water a key element of successful management as aides and diagnostic technicians, food
prohibited at-grade evacuation during and after extreme weather events. service and environmental services per-
of medical facilities; many New Many hospital campuses, such as the sonnel, administrators and engineers re-
Orleans hospitals had grade-level Texas Medical Center use underground quired to ensure that safe, quality patient
helipads. There was limited ability to tunnels as their primary form of pedestrian care continues uninterrupted. In addition
accommodate boats. Staff at Tulane and utility connectivity. Since the 2001 to full or part-time employees, there are
Medical Center removed light fixtures flood event, Texas Medical Center has often large numbers of contract consul-
from the parking garage roof to constructed a replacement building tants. Extreme weather events, like many
improvise a heliport when they could connection system for pedestrians, types of emergencies, cause transporta-
not access the ground level facility service and utilities at the second floor. tion disruptions and can result in signif-
due to flooding, then had to improvise Tampa General, as noted above, located icant restrictions on travel, ranging from
a safe transport route for patients. In its ED convenient to the parking garage high-occupancy restrictions on bridges to
Manhattan, hospitals are prohibited from area designated for patient surge to fuel rationing. In many instances, restric-
installing rooftop heliports. The only facilitate improved management in mass tions extend to “essential personnel” only,
viable evacuation route during Sandy casualty emergencies. and emergency preparedness plans have
was at grade once water subsided. often neglected to include non-clinical
Clearly, it is important that hospitals personnel in this category – which further
have redundancy in their evacuation exacerbates staffing shortages. Emerging
routes to avoid entrapment. electronic ID systems, downloadable to
smartphones, are promising to improve
The Federal Aviation Administration, this situation substantially, and will allow
Department of Transportation, and many critical facilities, such as hospitals and
insurance underwriters and industry nursing homes, to determine a broader
safety organizations recommend that group of personnel to classify as “essen-
all hospitals construct a permanent, tial workers” in emergency circumstances.
certified heliport landing area on their
property for safety. The decision to For shelter-in-place, critical personnel
place heliports on roof areas versus the may be required to remain on-site during
ground should include consideration of and after events. This can create an
flooding vulnerabilities. Heliports require
Figure 22: Debris outside the Joplin extremely stressful situation if immedi-
Hospital Emergency Department, following
fuel storage, which poses added risk on ate family members are left to fend for
the EF-5 tornado, complicated evacuation
rooftop areas. procedures. themselves at home. When communica-
tion systems are disrupted, as they often
In the aftermath of tornadoes and high are, the stress level among personnel can
wind events, debris (including parts of reach a critical level. In addition, person-
the hospital building) strewn around nel are often required to take on essential
the exterior of hospital properties roles that are beyond their general job
can make roadways and pedestrian description, and can be placed in harm’s
59
way. Hence, it is critical to engage front-

line workers in planning in order to under-
stand the organizational vulnerabilities (as
CASE STUDY: Community Medical Center, Barnabas
described in Part 2) that extreme weather Health, Toms River, NJ
events may reveal, and to prepare and
Community Medical Center, Toms River is located 50 miles north of where Superstorm Sandy
equip personnel for such circumstances.
made landfall, 8 miles from the Atlantic Ocean. While the 592-bed facility was safe from
Hospitals are increasingly preparing to direct storm impacts, the administration realized that more than 65% of their physicians
house substantial numbers of personnel, and employees lived in areas that were likely to be severely impacted—low-lying coastal
with families and their pets, during and communities and barrier islands that could have significant infrastructure and transportation
following extreme weather events. This disruptions—and 30% were in mandatory or recommended evacuation zones.
can mean securing nearby hotels, consoli-
Because of the advance warning, the hospital prepared. Supply deliveries, including non-
dating patients in order to use unoccupied
perishable food items, ice and water, were increased. Cots were deployed; an “employee
patient care units for staff, or repurposing
on-call, office, and conference areas for
concierge” was assigned. Rooms at a nearby hotel were secured. The cafeteria was
staff accommodation. If there is significant converted to male/female sleeping areas.
patient surge, options for personnel space Prior to the storm, approximately 300
may become severely limited. essential staff, their families, and pets were
relocated to the facility. Laundry facilities (3
In an era of “just-in-time” deliveries and sets of washers and dryers) and an internet
limited on-site inventory, severe weather café were installed in the hospital within
events can disrupt patient care if sufficient a week of the storm for staff use for the
supplies are not secured prior to the extended post- storm recovery period.
event. For advance notice events,
facilities that intend to shelter in place During the storm, the hospital lost normal
must secure sufficient food and supply power for close to 48 hours, and generators
inventories to operate for extended (and deployed. The hospital treated a large influx
difficult to predict) durations. Organizing of patients with minor injuries, the “worried
and storing these supplies in accessible well” in need of temporary shelter, and
location(s) out of harm’s way can present patients with special needs (asthmatics, Figure 23: This washed out bridge
space challenges, and stockpiles of dialysis, particular medications). Close to along the New Jersey shore following
supplies can expand beyond core 5,000 meals were prepared and served Superstorm Sandy demonstrates
medical items to include items that how vulnerable residential shoreline
each day in the 8 days following the storm;
personnel and their families may need communities can become disconnected
in addition, catered dinners were provided from transportation infrastructure; if
during the recovery period, such as
for staff and families. They distributed large numbers of medical personnel live
batteries and firewood. Hospital systems
ice, flashlights, batteries, and firewood in such communities, hospitals and long
that provide consolidated warehousing of
to employees that remained in their term care facilities must plan to relocate
medical supplies may have some
nearby homes without power. In total, 130 those staff prior to major storm events.
advantages, but should carefully consider
the potential for constrained access to employees lost homes or had homes that
affected hospital sites when planning for were not habitable following the storm,
centralized warehousing. Hospitals often while many others lost cars, clothing or personal belongings. Some lessons learned: staff
convert administrative areas, conference shower hot water systems should be on emergency power, as should outlets in office and
rooms, and other areas for emergency cafeteria areas that may be used as housing in surge situations (Bryant, 2013)
supply storage in order to address the
vulnerability of flood-prone storage areas
or the need for longer-term inventory.
60
Element 5: Environmental
CASE STUDY: Southeast Louisiana Veterans Health Care Protection and Strengthening of
Ecosystems
Center (SLVHCS), New Orleans, LA
Healthy ecosystems support life and
This 1,700,000 square foot replacement campus for the VA Hospital and Charity Hospital,
health. The United Nations Millennium
both closed following Katrina, incorporates a comprehensive set of resilience strategies Ecosystem Assessment (Corvalan,
unique to the challenges of post-Katrina New Orleans. A 7-day “defend in place” Hales, & McMichael, 2005) established
capability applies the lessons learned from Hurricane Katrina to create a resilient hospital that “ecosystems are critical to human
infrastructure. The facility can remain fully operational without outside support during a well-being—to our health, our prosperity,
disaster, with enough provisions and accommodations for up to 1,000 staff and patients. our security, and to our social and
cultural identity.” Ecosystem services are
Its floor elevation and critical functions are designed to survive a future levee failure. All
goods and services of direct or indirect
mission-critical mechanical and electrical infrastructure is located on upper levels, while
benefit to humans that are produced
required program components, such as the emergency department and patient beds, are
by ecosystem processes involving the
placed at least 20 feet above the established BFE. Ambulances use a dedicated ramp interaction of living elements, such as
to reach the facility (it can double as a boat launch). The kitchen is on floor 4, while the vegetation and soil organisms, and non-
cafeteria, deemed to be less critical, is on the ground floor—food travels in a dedicated living elements, such as bedrock, water,
elevator during normal operation. Travel from building to building can be accomplished and air.
entirely indoors at elevations well above the BFE.
This section is a review of how certain
The facilities energy plant stores 320,000 conventional, accepted land practices
gallons of fuel, enough for a full week, affect the interrelated operations of
and can collect and store over a million functioning ecosystems, followed by a
gallons of rainwater on-site to reduce use description of the benefits of adopting
of city water for cooling systems and other sustainable practices. The following
uses during normal operation and provide elements of ecosystem services should
needed water if the city supply is disrupted be supported:
or unavailable. There is also a 6,000-square • Treating water as a resource:
foot warehouse on-site to store emergency Eliminate unnecessary irrigation and
supplies. The building enclosure and harvest rainwater.
windows are designed to survive at least • Valuing soils: Improve infiltration,
Category 3 hurricane winds. The building reduce runoff, and filter stormwater.
contains an on-site sewage treatment • Preserving and enhancing
system capable of processing and holding Figure 24: The new Southeast Louisiana
vegetative cover and open
Veterans Health Care Center (SLVHCS)
waste for five to seven days. The parking space: Maintain wildlife corridors,
features a range of enhanced resilience
structure roof serves as a heliport, capable and infrastructure planning measures. habitat, wetlands, and reduce the
of supporting Black Hawk helicopters in The building is designed to operate for development footprint.
an evacuation (Healthcare Construction + a minimum of seven days, even if all of
Operations News, 2012). New Orleans’s utility and infrastructure
services are lost.
61
Valuing Soils: improve infiltration,

The New York City Green Infrastructure reduce runoff, and filter stormwater The Energy Independence and
Plan (2010) presents approaches to One of the key elements of sustainable Security Act of 2007 (EISA) instructs
improving water quality on-site through land use planning is a reversal in federal agencies to “use site
green infrastructure strategies. The approach to stormwater management. planning, design, construction, and
U.S. EPA has a Green Infrastructure Historically, stormwater has been treated maintenance strategies for the
website with tools and resources for as a nuisance, with both municipal and property to maintain or restore, to
building owners. on-site infrastructure focused on getting the maximum extent technically
rid of it as quickly as possible. In many feasible, the predevelopment
cities and towns, older stormwater hydrology of the property with regard
systems are combined with sewer to the temperature, rate … “ for any
Treating Water as a resource: systems, leading to significant overflows
eliminate unnecessary irrigation and project with a footprint that exceeds
of both in extreme rainfall events
harvest rainwater 5,000 square feet. For additional
or flooding. There has been limited
Water cycles through Earth’s
guidance and resources on Integrated
attention paid to the issue of impervious
atmosphere, oceans, land, and surfaces (parking, walks and roadways)
Stormwater Management practices,
biosphere; shaping weather and and the impact to duration of extreme see the EPA Stormwater Management
climate, supporting plant growth, and rainfall events. If water cannot soak into Best Practices website at http://www.
enabling life. On a well-vegetated site the ground, it moves deeper inland or epa.gov/oaintrnt/stormwater/best_
with healthy, open soils, rainwater is into basements and occupied areas. practices.htm.
absorbed and transpired by vegetation,
or soaks into the soil and is filtered as Rather than getting rid of stormwater as
it re-enters underground aquifers. In quickly as possible, a sustainable Key best practices of sustainable
developed areas, rainwater runs off into approach to stormwater management stormwater management include:
storm sewers, and is lost to the natural involves finding ways to harvest it on site
• Protecting and restoring existing
cycles. Landscapes have evolved to be and use it for irrigation, ornamental
hydrologic functions through
irrigation intensive, requiring massive water features, and groundwater
planting native or appropriate non-
amounts of water to be sustained recharge. Green roof (vegetated roofs)
native vegetation, re-grading soils
(as much as 5% of a hospital’s water and blue roof (stormwater retention)
where necessary, and restoring the
budget is used by landscape). Insofar technologies in urban areas reduce the
functions of floodplains, and riparian
as climate change is expected to impact volume of stormwater flow during
and wetland buffers
rainfall, leading to less frequent, more extreme rainfall events. Permeable or
pervious paving, reduced paved areas, • Managing stormwater on site by
intensive rainfall events, it becomes
constructed wetlands and management reducing impervious surfaces,
more important to view water as a
of natural bio-swales and stormwater harvesting rainwater, and directing
resource: harvesting rainwater and
catchment systems that recharge remaining stormwater runoff to
holding back stormwater discharge.
groundwater are also important soil and vegetation-based water
Separate metering and controls of
mitigation techniques that can be treatment methods, such as rain
irrigation system water allow health care
implemented at an individual site level. gardens, bio-swales, wetlands, and
facilities to suspend irrigation water use
Technology exists to integrate systems green roofs (groundwater recharge
(both potable and non-potable) during
that mimic nature’s capacity to store, is becoming increasingly important
drought emergencies.
filter, and clean water. This is particularly in aquifer-dependent regions of the
important for health care facilities that country)
rely on well water as either a primary or • Using stormwater for beneficial
backup potable water source. purposes (e.g., collecting it for
irrigation and other non-potable uses)
62
the precautionary observation that

future development would occur on
sites that had, generations earlier, been
pronounced “undevelopable” and
would bear additional costs and risks.
In Katrina, the historic French Quarter of
New Orleans—the originally developed
“high ground”—did not flood. Instead,
more recently developed, low-lying
communities bore the majority of the
damage.
In the coming decades, it will become

increasingly essential to evaluate
sites and their ecosystem services
contributions, and tailor development
decisions to prudent investment
choices. From understanding and
Figure 25: These bioswales at Kiowa County Memorial Hospital filter stormwater and supporting underlying site hydrology
support the Ogalalla Aquifer recharge. Rooftop rainwater is collected for irrigation and to important wildlife corridors,
toilet flushing. protecting and restoring underlying
ecosystem services as a tool to enhance
Preserving vegetative cover and resilience is emerging as an important
and is targeting its cooling and energy
open space: maintain wildlife consideration.
efficiency efforts, such as the cool roofs
corridors, habitat, and reduce and green roof grant programs, to those
development footprint areas. In addition, the City overlaid a
The continued urbanization and map of 311 and 911 calls regarding
disruption of natural systems, heat-related emergencies to assess the
particularly in urban areas and coastal correlation between urban heat islands
and riverine floodplains, intensifies the and heat stress-related issues. During
damage from extreme weather events. the past 15 years, Chicago planted
Urban heat island impacts intensify more than 500,000 trees and achieved a
health impacts from heat waves; City-wide tree count of 4.1 million trees.
impervious surfaces amplify surge and The City plans to plant approximately
inundation impacts. As communities 1 million new trees by 2020. They are
have in-filled wetlands and developed replacing 1,900 miles of paved alleyways
former floodplains, the damage from with permeable paving to infiltrate
extreme weather events has increased. stormwater and allow the alleyways to
It is important to preserve vegetative be part of a night cooling system (City of
cover and open space. Chicago, 2014).
The City of Chicago, which has More than a decade ago, it was
experienced extreme heat waves since recognized that, at least in highly
1995, has an aggressive program to developed regions, the vast majority of
reduce urban heat island impacts. The easily developable sites were developed.
City mapped Chicago’s hottest spots Architectural Record magazine offered
63
CASE STUDY: Texas Medical Center, Houston, Texas

In 2001, Tropical Storm Allison inflicted historic 1000-year flooding on downtown Houston, Texas—more than 80 miles inland from the coast.
Categorized as the costliest tropical storm in U.S. history, Allison parked itself over southeast Texas from June 5-9, 2001, dumping more than 3
feet of rain (almost 30 in. of which fell over a 48-hr period) on the Houston metro area. The storm statistics are startling: Allison left 22 dead and
caused almost $5 billion in damage to Harris County alone.
Texas Medical Center, a 700+ acre complex of 13 hospitals, two specialty institutions, two medical schools, four nursing schools, and schools
in various health-related professions, was virtually shut down as a result of flooded infrastructure: emergency generators, electrical switchgear,
and boiler and chiller plants all sustained damage. About 30,000 research animals, housed in the basement of Baylor College of Medicine,
drowned. Researchers saw years worth of work wiped out, including lab animals, computer data, lost records, and tissue samples.
The following systems were not operational after the storm: electrical power, emergency electrical power, HVAC, laboratory and fume hood
exhaust systems, domestic cold and hot water, compressed air and vacuum systems, fire detection and suppression systems, and basement
sanitary and storm sewer systems. Basements, which were interconnected among the 100 buildings, contained the incoming service from
Houston Light and Power (5kV) as well as several unit substations along with motor control centers, distribution panels, and transformers.
After the flood, all the institutions relocated critical infrastructure and program areas above projected flood elevations, a process that took
years to complete. At the same time, to lessen the impact of future storms like Allison, the Texas Medical Center organization, which acts as a
“city government” for the 42 hospitals, universities, and other institutions that make up Texas Medical Center, embarked on the development
of a long-term hazard mitigation plan. The plan, which continues to be implemented, incorporates 42 proactive sustainable design measures
to reduce the impact from future extreme weather events. Texas Medical Center consulted with hydrology experts and officials from the city of
Houston, FEMA, the Harris County Flood Control District, the Harris County Subsidence District, Reliant Energy, Southwestern Bell, and others,
demonstrating that resilience measures require the engagement of a broad range of stakeholders.
Key elements of the plan include:
• A new 48-megawatt central campus CHP utility plant run by its own power company, with distribution via an elevated utility walkway, that
both eliminates dependence on the Houston utility grid for necessary power and reduces carbon emissions by bringing electrical generation
on-site
• An advanced stormwater management system that prioritizes open space for stormwater recharge through advanced systems (this includes
completion of the Brays Bayou federal project, which flood control district officials say will lower the water level in Brays Bayou during a
storm comparable to Allison by five feet; partially funded by the federal government, the project includes widening the bayou, raising 31
bridges and adding a large water detention pond north of the Texas Medical Center)
• Requirements that all new developments on campus follow stormwater management guidelines and implement streetscape improvements—
designs based on such requirements improve access to nature for the campus by integrating landscape and water into the formerly highly
urbanized and paved campus
Texas Medical Center has implemented some additional measures, including installation of a solar-powered system that monitors subsidence
in the area. Since 1976, the medical center has subsided more than three and one-half feet due to the pumping of groundwater to be used as
drinking water, an important fact to consider in constructing new buildings at elevations high enough to be safe from future flooding. Potable
water conservation has become another key element of consideration.
64
Texas Medical Center, Houston, Texas continued MEASURING RESILIENCE:

NEED AND METRICS
“Enhancing the nation’s resilience will not
be easy, nor will it be cheap. But the urgency
is there and we need to begin the process
now in order to build a national ethos that
will make the nation safer, stronger, more
secure, and more sustainable for our children
and grandchildren.” -- Susan Cutter, Chair,
Committee on Increasing National Resilience
Figure 26: This aerial view of Texas Medical Center illustrates
the creation of landscape buffers to enhance stormwater to Hazards and Disasters; Committee on
management. Science, Engineering, and Public Policy, The
National Academies (2012)
Measurement of resilience is important

but elusive. Establishing metrics is
imperative if progress is to be measured.
Any effort to compare benefits of
increasing resilience with the costs
of improvements requires a basis of
measurement. At the moment, there
is no unified, consistent metric for
measuring resilience of health care
infrastructure.
Figure 27: A site plan of the proposed enhancements to
landscape and stormwater features, including the definition of a Resilience is not something health
landscape core at the heart of the medical campus. care organizations are experienced
with measuring. However, many
organizations have attempted to
measure resilience or vulnerability for
the U.S. using both community-based,
bottom-up approaches and top-down,
centralized measurement. For example,
the Coastal Resilience Index provides
an example of a community-based
approach to a self-assessment process
to derive an index of resilience to storm
events. The results are a Low, Medium,
Figure 28: Texas Medical Center improvements include elevated and High rating on specific elements,
walkways that provide utility distribution as well as advanced such as critical infrastructure, which are
stormwater management strategies. then correlated to produce an overall
state-of-the-community resilience score,
along with an estimate of the time it
65
would take for reoccupation of the The Council’s final recommendation • Phase One: Diagnosis and
community following a disaster. was that the Department of Homeland assessment of climate and health risk
Security, in conjunction with other • Phase Two: Assessing vulnerabilities
By contrast, the Argonne National federal agencies and public/private and risks to the institution
Laboratory Resilience Index measures partners, develop a National Resilience
the resilience of critical infrastructure • Phase Three: Developing a resilience
Scorecard that could be used by
through a highly structured and adaptation plan
communities to indicate the ability of
interview process conducted by the critical infrastructure, including health • Phase Four: Implementing the plan
Department of Homeland Security’s care infrastructure, to withstand or • Phase Five: Evaluating and revising
Protective Security Advisors. Using recover rapidly from impacts; indicators the plan
an infrastructure survey tool, these of the ability of buildings and other
interviews cover more than 1,500 critical structures to withstand the
variables. A five-stage aggregation physical and ecological impacts of INVESTING IN RESILIENCE
process is then used to combine the disasters; and factors that capture There are many reasons for a health
items into a single Resilience Index the special needs of individuals and care organization to prioritize resilience
(called the Protective Measure Index, groups, including vulnerable health as part of its community leadership
or PMI) that ranges from 0 (lowest status populations. In order to inform and sustainability agendas. The
resilience) to 100 (highest resilience) future development of such an index, United Nations Office of Disaster Risk
for a given critical infrastructure or key health care organizations should begin Reduction (UNIDSR, 2012) notes:
resource sector and for a given threat. the process of assessing and measuring “Paying attention to protection and
To date, the DHS has performed this resilience. resilience will improve environmental,
assessment for more than 200 hospitals. social and economic conditions,
including combating the future variables
In 2011, The National Research Council
(2012) convened a committee to review EMBEDDING RESILIENCE of climate change, and leave the
community more prosperous and secure
the state of resilience metrics both IN INFRASTRUCTURE than before.”
in the U.S. and globally. Their report DECISIONS
recommended the following (modified The World Health organization (WHO)
here to apply to an institutional level): “Current efforts are hampered by a lack of
calculates that the price for retrofitting
• Any approach to measuring resilience solid information about the benefits, costs, the non-structural items costs as
must address multiple hazards and and effectiveness of various adaptation little as 1% of the value of a hospital,
must be adaptable to the needs of options, by uncertainty about future climate while possibly protecting up to 90%
specific institutions or communities of the hospital’s assets (2009). FEMA
and the hazards they face.
impacts at a scale necessary for decision-
(2007) notes that the most common
• Resilience measurement must be
making, and by a lack of coordination” points of hospital failure from storms
place-based and capable of dealing (Wilbanks, Yohe, Mengelt, & Casola, 2010). are the elevator machinery, windows,
with a wide range of sizes. and generators. Bolstering protection
This Guide represents a first step in of these building assets often costs
• An index must include many
understanding the components of less than the cost to rebuild. In
dimensions, from the physical
infrastructure resilience; the Toolkit addition, many building elements and
resilience of the built and natural
begins the process of embedding this infrastructure equipment are replaced
environment and critical infrastructure
thinking into infrastructure decision in the course of a hospital building’s
to aspects of human/social resilience,
making. It outlines a five phase process useful life. The rising cost of energy
such as the existence of strong social
that institutions can take to understand is making energy retrofits more cost-
and health care networks, a strong
and improve their resilience to the effective; improving resilience aspects of
economic base, or good governance.
climate and health challenges of today mechanical and electrical infrastructure
and the future: while retrofitting for improved energy
66
performance provides multiple benefits in the form of mitigation, costs much

from a single investment. By contrast, less than the direct cost of repair and CONCLUSION
hospital damages from extreme weather indirect cost of rebuilding the community
“… the science, engineering, and emergency
events range from $600,000 to $2 billion around it. Certainly, there are social
per facility. Meteorologist Wendy Marie and human gains achievable: lives and management solutions needed to protect
Thomas (2011) noted that “mitigation for property saved in disaster or emergency these critical infrastructures and to promote
hospital buildings is likened to the health situations, with a dramatic reduction continuity of operations already exist. [The
adage that says ‘an ounce of prevention in fatalities and prompt treatment of
goal] is to tap the available potential in this
is better than a pound of cure.’” serious injuries. Less damage leads to
protected community assets and cultural nation to protect the only infrastructure
Mercy Hospital, Joplin, believes that it heritage, with less diversion of hospital that provides for our health, and is a major
incurred cost premiums in the range of and community resources to disaster piece of the engine that keeps the nation
3% for its tornado resilience measures; response and recovery.
Spaulding Rehabilitation Hospital in moving.” Wendy Marie Thomas, American
Boston estimates the premium for Meteorological Society Policy Program (2008)
coastal flooding resilience is in the “The most costly hospital is the one that
range of 0.3%. For new buildings, fails.” World Health Organization, 2009 This Guide and Toolkit highlights how
these examples suggest that increased extreme weather events can cause
resilience is achievable for modest building failures that ultimately disrupt
financial investments. The investments in Finally, while a comprehensive business the continuum of health care delivery
energy efficiency offer financial payback case for hospital resilience has not been during the events and in their aftermath.
of immediate to as much as 8 years—for developed, UNIDSR suggests that an Focused attention on protecting the
health care organizations that own large important benefit of resilience planning physical infrastructure of hospital
building portfolios, even 8 year payback is assurance for public and private and residential care settings can
(or 12.5% rate of return) can be viewed investors in anticipation of fewer disaster offer some increased ability to keep
as cost-effective. losses, leading to increased private buildings and people safe through future
investment in homes, buildings and climate change scenarios. It requires
From the immediate disruptions to the other properties that comply with safety a combination of meteorological data
lasting impacts of storm devastation standards and build community wealth. and climate scenario forecasting to
on communities profiled in this Guide, Uninterrupted medical services means understand risk, engineering knowledge
a picture emerges of the importance preserving employment for the hospital to prepare existing and new health care
of health care institutions, such as and allied businesses that depend buildings to manage and adapt to those
hospitals and nursing homes, in coming upon a functioning health care setting risks, and investments in strengthening
through these events with a minimum for their livelihood; extended disruption ecosystem services to mitigate the
of disruption, and supporting the larger often leads to loss of a pivotal economic effects of such events. The Guide and
community in the enormous task of anchor in communities. In the aftermath Toolkit consolidates the lessons learned
recovery and adapting to what may well of Katrina, the New York Times reported and emergent practices for resilient
be a “new normal.” “Of all the factors blocking the economic health care infrastructure that can be
revival of New Orleans, the shattered gathered from the extreme weather
The World Health Organization (WHO) events of the past two decades in order
health care system may be the most
launched its Save Lives: Make hospitals to inform the design and planning of
important —and perhaps the most
safe in emergencies campaign in 2009 critical health care infrastructure in the
intractable” (Eaton, 2007).
to raise attention to the number of health decades ahead.
and societal dominoes that fall when
disasters strike hospitals. It proclaimed Unlike a single FEMA Mitigation
that the “most costly hospital is the one Assessment Team report or a regional
that fails.” This is because prevention, post-disaster guidance document, this
67
Guide and Toolkit focuses on health

care infrastructure and its response to
any and all weather hazards in order
to find both practices and strategies
that serve the unique programmatic
and patient safety realities of health
care settings as well as hazard-
specific infrastructure responses. In
so doing, it allows health care owners
to identify potential strategies that can
improve resilience to not only extreme
weather events already experienced in
a region, but possible future weather
events as well. It can assist health care
organizations in selecting strategies
that improve responses to multiple
potential hazards—from heat waves to
cold waves, tornadoes to flooding. It
consolidates meteorological tools, case
studies, and resources prepared by
federal agencies, states, cities, as well
as the private sector.
It builds upon the challenge outlined

above: to protect the infrastructure that
protects the nation’s health. There can
be no higher purpose, and no greater
success, than to inform health care
infrastructure design toward a more
resilient and sustainable future. This is
the promise of the President’s Climate
Action Plan. The imperative is clear.
68
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Primary Protection: Enhancing Health Care Resilience for a Changing Climate AUTHORS AND ACKNOWLEDGEMENTS
ABOUT THE AUTHORS ACKNOWLEDGEMENT

Robin Guenther, FAIA, LEED Fellow, John M. Balbus, M.D., M.P.H., is the OF STAKEHOLDER
is a practicing architect and author, Senior Advisor for Public Health to COMMENTS
Principal at Perkins+Will and Senior the Director of the National Institute
The authors thank the following
Advisor to Health Care Without Harm. of Environmental Health Sciences
individuals for their valuable comments
Robin works at the intersection of health and Director of the NIEHS-WHO
during the stakeholder review process:
care architecture and sustainable policy Collaborating Centre for Environmental
• John Cutler
and participates in a wide range of Health Sciences. He serves as HHS
initiatives while continuing to practice. principal to the U.S. Global Change • Kim Dyches
In 2013, following Superstorm Sandy, Research Program (USGCRP) and also • Sarah Goes
Robin co-chaired the Critical Buildings co-chairs working groups on Climate
• Cindra James
Committee of the New York City Building Change and Human Health for the
USGCRP and for the National Institutes • Sherline Lee
Resiliency Task Force. She serves on the
U.S. Green Building Council (USGBC) of Health. Balbus was a lead author for • Hubert Murray
Green Buildings and Human Health Task the health chapter of the 3rd US National • Clark Reed
Force, co-coordinated the Green Guide Climate Assessment. He served as
review editor of the Urban Areas chapter • Matthew Schilling
for Health Care, served on LEED for
for the recent 5th Assessment Report • Christina Vernon
Healthcare committee, and released the
of the Intergovernmental Panel on • Jalonne L. White-Newsome
second edition of Sustainable Healthcare
Climate Change and is a co-convening
Architecture with Gail Vittori in May 2013.
lead author of the ongoing USGCRP
She served on the 2006 and 2010 FGI
Climate Health Assessment. Balbus
Guidelines Revision Committee. She received his A.B. degree in Biochemistry
holds a Master of Architecture degree from Harvard University, his M.D. from
from the University of Michigan, a the University of Pennsylvania, and his
Graduate Diploma from the Architectural M.P.H. from the Johns Hopkins School
Association, London, and is a Fellow of of Public Health.
both the American Institute of Architects
and the US Green Building Council.
80
82

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PART 1

Primary Protection: Enhancing Health Care Resilience for a Changing Climate

U.S. Department of Health and Human Services

Cover Photo Credits:

Institution-level Infrastructure: Assessing Hazards and

PART 2: THE CURRENT STATE OF HEALTH CARE

The State of Florida’s Path to Increased Health Care Resilience

CASE STUDY: Miami Children’s Hospital, Miami, Florida

Lessons Learned from Hurricane Katrina

Inland Flooding from Extreme

Natural variability cannot explain the

Cities and states have relied upon basin

Given the increase in threshold

CASE STUDY: Mercy Medical Center, Cedar Rapids, Iowa

Figure 4: Mercy Medical Center, Cedar

Droughts are likely to become more

of re-insurer Aon Benfield (Rice and

evacuated in June, 2014 when a 100

elevation to which protection is including placing additional systems

Primary reason for disruption Secondary Reason Tertiary reason

PART 3: SOLUTIONS FOR THE FUTURE

• What types and magnitudes of “A resilience-based approach focuses on

Resilient Design Principles

This Guide and Toolkit is focused at the improvement of resilience in health

facilities located in areas that may be

“The aim should be to anticipate and

CASE STUDY: Spaulding Rehabilitation Hospital, Boston, MA

Hospital and long term care campuses

the DFE. At a minimum, a hospital’s

The following strategies highlight

model national building codes to

Newer local regulations have moved

to determine how such performance

CASE STUDY: Louisiana Heart Hospital, Lacombe, LA

Figure 15: Louisiana Heart Hospital,

Strategies to extend passive survivability

Infrastructure protection and resilience is

As backup generator systems expand in

CHP systems are a highly efficient

in a future with stressed potable water

The capturing of on-site rainwater as

CASE STUDY: Kiowa County Memorial Hospital, Greensburg, KS

“We expect prompt medical attention for an

way. Hence, it is critical to engage front-

Valuing Soils: improve infiltration,

the precautionary observation that

In the coming decades, it will become

CASE STUDY: Texas Medical Center, Houston, Texas

Texas Medical Center, Houston, Texas continued MEASURING RESILIENCE:

Measurement of resilience is important

performance provides multiple benefits in the form of mitigation, costs much

Guide and Toolkit focuses on health

It builds upon the challenge outlined

PART 1: INTRODUCTION TO THE GUIDE AND TOOLKIT

Act for Climate Justice (2014). Retrieved from http://www.actforclimatejustice.org/about/what-is-climate-justice/

Department of Homeland Security (2013). What is critical infrastructure? http://www.dhs.gov/what-critical-infrastructure

FEMA (2014). Critical Facility. http://www.fema.gov/national-flood-insurance-program-2/critical-facility

Resilience Alliance (2014). http://www.resalliance.org/560.php

PART 2: THE CURRENT STATE OF HEALTH CARE INFRASTRUCTURE CLIMATE