Topic Collection Cover Page

Utility Failures
Topic Collection
April 1, 2024

Topic Collection: Utility Failures

Losing power or water can have serious effects on communities, healthcare facilities, staff, and patients. Either situation could lead to healthcare facility evacuation, as utilities are significantly interdependent within the community and healthcare facilities. The resources in this Topic Collection include lessons learned from recent disasters, case studies, and toolkits designed to help healthcare planners prepare to respond to, continue functioning during, and recover from utility failures.

Planners may also wish to access several other related ASPR TRACIE Topic Collections, including: Populations with Access and Functional Needs, Healthcare Facility Evacuation/Sheltering, Dialysis Centers, and Continuity of Operations (COOP)/ Business Continuity Planning.

Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category.


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Must Reads

ASPR TRACIE. (2021). Managing the Storm After the Storm: Healthcare in TX Recovers from Severe Winter Weather.
Michael Wargo (HCA Healthcare), Scott Cormier (Medxcel), and Toni Carnie (HCA Houston Healthcare Tomball) share how a rare winter storm, extreme cold, and unplanned power outages affected utilities--particularly water and water pressure--in healthcare facilities throughout Texas. This summary highlights issues that will benefit from additional mitigation and preparedness activities as extreme weather incidents increase in frequency.
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ASPR TRACIE. (2023). Utility Failures in Health Care Toolkit.
Utility failures are a major concern for health care and may cause substantial harm to patients, staff, and facilities. Threats include infrastructure damage due to natural disasters and other incidents, planned outages to relieve stress on services or prevent other hazards, and malicious acts such as physical and cyber sabotage. It is also important to note the cascading effects a failure of one utility may have on others; more than one utility may fail simultaneously or sequentially. This suite of tip sheets can help health care facility managers and emergency planners identify issues to consider when planning for and responding to various types of utility failures.
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California Emergency Medical Services Authority. (2017). Incident Planning Guide: Utility Failure.
This document includes a series of questions to guide hospitals in planning for utility failures associated with systems such as power, water, heating, ventilation, air conditioning, medical air, vacuum, or medical gases.
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California Hospital Association. (n.d.). Loss of Utilities/Services. (Accessed 11/10/2023.)
This webpage includes links to many resources related to healthcare facilities preparing for and responding to utility outages. There are links to presentations, tools categorized by utility system, best practices, and lessons learned.
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Centers for Disease Control and Prevention and American Water Works Association. (2019). Emergency Water Supply Planning Guide for Hospitals and Health Care Facilities.
This comprehensive document provides a four-step process for the development of a hospital emergency water supply plan and includes tips for assembling the right planning team, performing a water use audit, analyzing alternatives, and developing and exercising the plan. It is also available in Spanish: https://www.cdc.gov/water-emergency/media/pdfs/19_302124-EWSP-GUIDE-SPANISH.pdf.
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  • Rodney Merritt Onsite Water Management can prevent Hospital water outages.
    9/23/2020 2:27:59 PM
Cybersecurity and Infrastructure Security Agency. (2022). CISA Resilient Power Best Practices for Critical Facilities and Sites.
This document provides health care facility emergency and continuity managers with guidelines, analysis, background material, and references to increase the resilience of backup and emergency power systems during all durations of power outages.
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Federal Emergency Management Agency, Office of the Assistant Secretary for Preparedness and Response. (2019). Healthcare Facilities and Power Outages: Guidance for State, Local, Tribal, Territorial, and Private Sector Partners. U.S. Department of Homeland Security; U.S. Department of Health and Human Services.
The guidance in this document can help state, local, tribal, and territorial governments, first responders, utility companies, and healthcare facilities improve facility preparedness; understand how to "integrate emergency preparedness efforts throughout the whole community;" and prioritize assistance to healthcare facilities during power outages.
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Klinger, C., Landeg, O., and Murray, V. (2014). Power Outages, Extreme Events and Health: A Systematic Review of the Literature from 2011-2012.
The authors identified 20 articles that examined the effects of power outages on health. Table 5 highlights the impacts by category (e.g., hospital, healthcare, community, and public health infrastructure).
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Stymiest, D. (2016). Best Practices for Hospital Power System Reliability.
The author lists best practices for healthcare facility planners to consider regarding preventing, preparing for, and responding to power outages.
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Community Impacts of Utility Failures

ASPR TRACIE. (2021). Durable Medical Equipment in Disasters.
This ASPR TRACIE tip sheet provides information on general durable medical equipment (DME) categories and focuses on electricity-dependent DME that may be affected by disasters and emergencies, including power failures. It also includes information to assist healthcare system preparedness stakeholders plan for populations who rely on DME.
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Casey, J., Fukurai, M., Hernández, D., et al. (2021). Power Outages and Community Health: A Narrative Review. Current Environmental Health Reports. 7(4):371-383.
The authors reviewed 50 articles mentioning power outages related to disasters published between 2004 and 2020. The results indicate that power outages impact health, especially for individuals who rely on electricity-dependent medical equipment. Lack of electricity was associated with carbon monoxide poisoning, gastrointestinal illness, temperature-related health issues, and respiratory, cardiovascular, and renal disease hospitalizations.
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Casey, J., Mango, M., Mullendore, S., et al.. (2021). Trends from 2008–2018 in Electricity-Dependent Durable Medical Equipment Rentals and Sociodemographic Disparities. Epidemiology. 32(3): 327–335.
The authors used Kaiser Permanente South California electronic health record data to calculate annual prevalence of equipment rental, then stratified it by rental of breast pumps or other equipment. Their findings "suggest that energy access is increasingly critical in meeting the health needs of medically disadvantaged groups" and the need will only increase as the number of disaster-related power outages increases.
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Centers for Disease Control and Prevention. (2014). Clinical Guidance for Carbon Monoxide (CO) Poisoning After a Disaster.
This guidance can help healthcare providers determine whether patients are suffering from carbon monoxide poisoning (more likely to be an issue after a power outage, when residents are using generators).
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Choose Energy. (2019). Electricity Emergency Preparedness for Senior Citizens and their Caretakers.
The guidance on this web page can help older adults and their caretakers plan for, respond to, and recover from power outages.
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Cote, E., Peterson, L., Evans, A., and Nil, M. (2023). Advancing Preparedness for Life Support Users During Power Outages.
As power outages increase in frequency and duration, many people who depend on life support and other types of durable medical equipment will face challenges maintaining the power needed for their equipment. This report describes how a pilot project launched in July 2021 by the Louisiana Department of Health helped minimize risk to medical device users and reduced drain on hospitals, ambulance providers, and shelters during emergencies.
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* Do, V., McBrien, H., Flores, N., et al. (2023). Spatiotemporal Distribution of Power Outages with Climate Events and Social Vulnerability in the USA. Nature Communications. 14. .
The authors reviewed power outages from 2018–2020, and found "an average of 520 million customer-hours total without power annually across 2447 US counties (73.7% of the US population)." Longer outages were more likely to occur in northeastern, southern, and Appalachian counties, while counties in Arkansas, Louisiana, and Michigan experienced both frequent 8+ hour outages and higher social vulnerability and prevalence of electricity-dependent durable medical equipment use. Considerations for disaster preparedness and response are included.
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HHS emPOWER Program. (2020). Stories from the Field: Blizzards in Goshen County, Wyoming.
During back-to-back severe blizzards, Goshen County, Wyoming, used the emPOWER Emergency Response Outreach Dataset to support numerous multi-agency coordinated response outreach activities to at-risk individuals directly impacted by the severe storms and hazardous conditions. The county partnered with the Sheriff’s office to identify areas where at-risk individuals resided in the areas affected by the power outages, then coordinated with the Sheriff’s office to conduct approximately 25 targeted wellness checks by phone.
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HHS emPOWER Program. (2020). Stories from the Field: Wildfires in Los Angeles County, California.
During severe wildfires, Los Angeles County, California, used the emPOWER Emergency Response Outreach Individual Dataset to rapidly conduct outreach to near 40 durable medical equipment (DME) and oxygen suppliers to provide recovery assistance to more than 600 individuals impacted by the historic wildfires. LA County also developed a formal multi-agency LA County-City of LA protocol that rapidly operationalizes data and supports integrated situational awareness, decision-making and action prior to, during, and after an emergency.
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Huff, C. (2021). Growing Power Outages Pose Grave Threat To People Who Need Medical Equipment To Live. National Public Radio (NPR).
The author describes how people who rely on electricity to power medical devices for daily life are affected by increasing power outages associated with climate change, highlighting how one ambulance provider responded to more than 50 calls in a two-day period from residents who rely on electricity powered life-sustaining equipment The author notes the benefit of programs such as the federal emPOWER program, which maps where people who rely on medical devices live, to facilitate public health and emergency preparedness and response.
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Johnson-Arbor, K., Quental, A., and Li, D. (2014). A Comparison of Carbon Monoxide Exposures after Snowstorms and Power Outages. American Journal of Preventive Medicine. 46(5): 481-486.
The authors reviewed all carbon monoxide cases reported to the Connecticut Poison Control to better understand the difference between exposure after a snowstorm and exposure after a "power loss storm." They found most exposure took place within the first day after a snowstorm and two to three days after the power outage storm.
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New York City Department of Health and Mental Hygiene. (2020). Disaster Preparedness for Children with Disabilities: Durable Medical Equipment.
This document (available in a variety of languages) was created to help people caring for a child with a disability make better informed decisions about the child’s health and safety, and support the implementation of public-private collaborations in communities during a disaster.
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Sheridan, S., Zhang, W., Deng, X., et al. (2021). The Individual and Synergistic Impacts of Windstorms and Power Outages on Injury ED Visits in New York State. (Abstract only.) The Science of the Total Environment.
The authors used New York State Department of Health data to identify how emergency department (ED) visits and lengths of stays were affected by wind strength, thunderstorms, or power outages. The study found that there was a significant increase in ED visits, length of stay, and cost during wind events and power failures. Healthcare emergency planners can use these results to plan for natural disasters and utility outages in their communities based on the impact to their facilities.
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Webb, E., Balaji, L., Nathanson, L., et al. (2021). Who's at Risk in a Changing Climate? Mapping Electricity-Dependent Patient Populations in a Coastal City. Rhode Island Medical Journal. 104(9):14-19.
The authors used geographic information systems to analyze the relationship between patients who use a nebulizer (which is electricity-dependent) and census block data that determined areas in and around Boston at risk for flooding during hurricanes. They found that of 2,101 patients with nebulizer prescriptions, 24.8% lived in a hurricane flood zone, demonstrating how hospitals can assess the potential effect of environmental hazards on electricity-dependent patients using publicly available data.
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Education and Training

Federal Emergency Management Agency. (2016). IS-815: ABCs of Temporary Emergency Power.
This course can help emergency planners and responders understand the requirements associated with providing temporary generator power to facilities.
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Federal Emergency Management Agency. (2021). IS-553.A: Coordination Between Water Utilities and Emergency Management Agencies.
This one-hour course provides information on key utility services, such as drinking water and wastewater, emergency services, and the impact of their disruption. It emphasizes coordination and relationships between sectors, and actions to improve the preparedness and response of these utilities.
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Texas A&M Engineering Extension Service. (2023). Disaster Awareness for Water and Wastewater Utilities, an Introduction.
This two-hour course covers response and recovery for disasters which affect drinking water and wastewater, how the systems may be vulnerable, and the potential impact. It uses the lens of the Environmental Protection Agency’s Response Protocol Toolbox and includes scenarios to show how multiple hazards might affect a utility.
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Virginia Department of Public Health. (2013). Don't Sweat It: Preparing for Disasters in Nursing Homes and Assisted Living Facilities.
This video was developed to be an educational tool for staff training on emergency preparedness specific to long-term care facilities. The scenario follows staff as they deal with a major storm that causes a week-long power outage. The video covers topics including preparedness, sheltering in place, and evacuation.
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Guidance

ASPR TRACIE. (2023). Impacts of Planned and Unplanned Power Disruptions on California's Public Health and Medical Systems.
This resource summarizes key takeaways which, in addition to understanding power supply regulations in your jurisdiction, can help health care emergency planners prepare facilities, staff, and patients for public safety power shutoffs and outages in general.
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Baker, G.H. and Volandt, S. (2018). Cascading Consequences: Electrical Grid Critical Infrastructure Vulnerability. Domestic Preparedness.
This article provides an overview of the national power grid, and related threats (e.g., coordinated physical attacks, cyber-attacks against industrial control systems, electromagnetic pulse denotation, and severe solar storms). The authors examine risks, threats, impacts, current state of preparedness, and conclude with recommendations to enhance critical infrastructure resilience.
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* California Hospital Association. (n.d.). Loss of Utilities/Services. (Accessed 11/10/2023.)
This webpage includes links to many resources related to healthcare facilities preparing for and responding to utility outages. There are links to presentations, tools categorized by utility system, best practices, and lessons learned.
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Centers for Disease Control and Prevention. (2014). Impact of Power Outages on Vaccine Storage.
This resource provides tips on maintaining the integrity of vaccine supplies during a power outage.
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Cybersecurity and Infrastructure Security Agency. (2022). CISA Resilient Power Best Practices for Critical Facilities and Sites.
This document provides health care facility emergency and continuity managers with guidelines, analysis, background material, and references to increase the resilience of backup and emergency power systems during all durations of power outages.
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Dudley, K. and Flannery, J. (2019). Comprehensive Utility Failure Plans.
The authors emphasize the importance of relationships and communication between emergency management and facilities staff at a healthcare organization during a utility failure. The article lists important questions to consider and key components when creating a utility failure plan (e.g., purpose, authority, parameters, procedures, and emergency clinical interventions). (Note that the authors also list several outdated Joint Commission elements of performance; readers are encouraged to access updated standards to ensure compliance.)
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Electromagnetic Pulse Special Interest Group. (2017). Resilient Hospitals Handbook: Strengthening Healthcare and Public Health Resilience in Advance of a Prolonged and Widespread Power Outage.
This document can help healthcare facility managers and planners increase resilience, plan for extended power outages, and create and store enough power on-site to operate in "island mode" for a prolonged period of time without outside sources of power or fuel. It outlines challenges and opportunities to solve a number of high-impact threats to critical infrastructure that can result in a regional or nationwide months-long power outage, making it unlikely for timely outside help to arrive.
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Environmental Protection Agency. (2023). A Critical Connection: The Water and Healthcare/Public Health Sectors.
This article describes how healthcare organizations can work with public health, utility companies, and other stakeholders to ensure continuity of potable water and wastewater services. Strategies include building relationships, coordinating preparedness and water use advisories, cooperating with poison control centers, supporting water quality improvement, knowing the Incident Command System, and coordinating with local emergency management.
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Federal Emergency Management Agency. (2020). Resilience to Power Outages in Healthcare Facilities.
This article contains information on the various electricity requirements of health care facilities and best practices during power outages. Recommendations include conducting vulnerability assessments of emergency power systems, regularly maintaining generators, conducting a disconnect test, and planning for the effects of a disaster on vendors’ capabilities.
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Federal Emergency Management Agency, Office of the Assistant Secretary for Preparedness and Response. (2019). Healthcare Facilities and Power Outages: Guidance for State, Local, Tribal, Territorial, and Private Sector Partners. U.S. Department of Homeland Security; U.S. Department of Health and Human Services.
The guidance in this document can help state, local, tribal, and territorial governments, first responders, utility companies, and healthcare facilities improve facility preparedness; understand how to "integrate emergency preparedness efforts throughout the whole community;" and prioritize assistance to healthcare facilities during power outages.
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Ferris, J. and Johnson, A. (2021). Emergency Preparedness and Utility Infrastructure in Healthcare. Patient Safety & Quality Healthcare.
The authors discuss how healthcare facilities can prepare their utility systems for any hazard. They recommend being aware of possible disasters in the facility’s geographic area and modernizing equipment such as the building automation system (which maintains temperature, pressurization, and humidity). They also recommend using emerging technology to ensure there is back up power, and testing equipment such as generators before they are needed in an emergency.
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HHS emPOWER Program. (2023). HHS emPOWER Program Platform.
Partners ranging from public health authorities to first responders and community organizations can access and use emPOWER’s publicly available tools, which includes the HHS emPOWER Map, REST Service, and emPOWER AI, which provides monthly updated de-identified total at the national, state, territory, county and ZIP Code levels for Medicare beneficiaries currently enrolled in the Centers for Medicare and Medicaid Services (CMS) Medicare Fee-For-Service (Parts A/B) or Medicare Advantage (Part C). It also provides monthly updated totals who have had an administrative claim for one or more life-maintaining or saving electricity-dependent durable medical and assistive equipment (DME) and devices. Public health authorities and their approved partners can use the HHS emPOWER Emergency Planning Dataset, which is a restricted tool that provides monthly total counts of Medicare claims by electricity-dependent DME and devices, health care services, and also at-risk combinations of these data at state, territory, county, major metropolitan areas, District of Columbia, and ZIP Code levels. In the event of an incident, emergency or disaster, an authorized public health authority may submit an official request for the restricted and secure HHS emPOWER Emergency Response Outreach Dataset to conduct life-saving assistance and response outreach health activities. For detailed information on the types of DME and devices, health care services, and at-risk combinations, access the Quick Data Reference Guide.
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Karfunkle, M. (2018). Safeguarding the Cold Chain with Solar Power. U.S Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
While solar panels alone can’t power a larger facility, small facilities like health posts can run entirely on solar power with batteries, and many critical systems in a larger facility like a clinic or hospital can run independently from the facility’s power lines as modular, electrically isolated systems. This presentation explains the "cold chain" process in healthcare, illustrates the requirements of a solar vaccine refrigerator, and shows users how to use NASA data to calculate insolation (amount of solar energy per unit area per day that hits an area).
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Powered for Patients. (2020). Protecting Patients When the Power Goes Out: Phase I Report of the Los Angeles County EMS Agency’s Emergency Power Resilience Initiative.
This report describes Phase 1 of a joint project between Los Angeles County Emergency Medical Services Agency and Powered for Patients. The gap assessment was conducted to evaluate the current process used by critical healthcare facilities to report threats to emergency power during a power outage and the response to such reports by government officials and utilities. Key findings and recommendations are highlighted throughout the document and summarized at the end.
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Roberson, A.J. and Hiltebrand, D. (2010). Emergency Water Supply Planning, Part 1: Hospitals and Health Care Facilities. (Free registration required.) American Water Works Association. 102(5): 36, 38, 40.
The authors of this article discuss the impact of water supply loss on hospitals and other health care facilities. They also address the Centers for Disease Control and Prevention and American Water Works Association’s "Emergency Water Supply Planning Guide for Hospitals and Health Care Facilities" document and note the goal of this project was to provide guidance for health care facilities in evaluating their water use and determining how it might be curtailed in an emergency, and in developing an emergency water supply plan for the facility.
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Stymiest, D. (2015). How to Plan for Water Outages. Health Facilities Management.
The author lists best practices for healthcare facility planners to consider regarding preventing, preparing for, and responding to water outages.
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Stymiest, D. (2016). Best Practices for Hospital Power System Reliability.
The author lists best practices for healthcare facility planners to consider regarding preventing, preparing for, and responding to power outages.
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Stymiest, D. (2017). Planning for Hospital Utility Failures and Recovery.
The author discusses the Center for Medicare & Medicaid Services’ requirements for utilities and operational infrastructure in a hospital, describing the importance of redundancies, and how to respond after a utility failure. The author provides examples of key hospital systems and potential failure points, and defines organizational memory, which is knowledge passed on from staff to newcomers, and its role in responding to utility failures.
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* U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2019). The Department of Health and Human Services emPOWER Program: emPOWERing Communities Through New Practical Applications, Training, Informational Resources, Toolkits, Maps, and Virtual Assistants.
The first speaker provided an overview of emPOWER and highlighted new data, tools, and resources. Subsequent speakers (from Los Angeles County and the Virginia Department of Health) shared their experiences using the tool and how patients (including those with electrical dependent DME such as ventilators or oxygen concentrators could be contacted/assisted.
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U.S. Environmental Protection Agency. (2023). Emergency Drinking Water Supply Guidance.
This webpage links to two resources that can help healthcare facility water and wastewater planners work with community partners to develop emergency drinking water supply plans.
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U.S. Food and Drug Administration. (2015). Medical Devices Requiring Refrigeration.
Tips for storing common medical devices and other products during and after a power outage are listed on this webpage.
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U.S. Food and Drug Administration. (2018). Disposal of Contaminated Devices.
This resource provides tips on checking medical devices for contamination and disposing of contaminated products in order to help pharmacies return to business as soon as possible following flooding or loss of power.
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Williams, M. (2016). Healthy Energy: Creating Outage-Resilient Hospital Facilities. In this blog post (which unfortunately does not reference the source of some of its statistics), the author explains the "Energy Network of Things" concept of system monitoring and how it can contribute to a healthcare facility's resilience in a power outage. Healthcare Facilities Today.
In this blog post, the author explains the "Energy Network of Things" concept and how it can contribute to a healthcare facility's resilience in a power outage.
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Lessons Learned

Abir, M., Jan, S., Jubelt, L., et al. (2013). The Impact of a Large-Scale Power Outage on Hemodialysis Center Operations. Prehospital and Disaster Medicine. 28(6): 543-6.
The authors examined how power outages in Washington, DC, and five counties in West Virginia and Maryland impacted operations in a sample of 36 hemodialysis centers. They found that those with pre-existing plans, including provisions for back-up generators and referral agreements with other dialysis centers, offered continuity of care to their patients.
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Anderson, G. and Bell, M. (2012). Lights Out: Impact of the August 2003 Power Outage on Mortality in New York, NY. Epidemiology. 23(2): 189-193.
The authors examined the effect of a large U.S. blackout (2003, New York) on mortality. They found a 122% increase in accidental deaths, a 25% increase in non-accidental deaths, but their estimates of mortality risk exceeded actual reported mortality.
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ASPR TRACIE. (2018). Going with No Flow: Coping with Hospital Water Supply Issues.
ASPR TRACIE interviewed Craig DeAtley (PA-C, Director, Institute for Public Health Emergency Readiness, MedStar Washington Hospital Center) to discuss the facility's response to a 2018 water outage.
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ASPR TRACIE. (2021). Identifying and Overcoming Healthcare Communications Vulnerabilities: Nashville, TN.
While the Christmas morning blast in Nashville did not cause a mass fatality incident, it significantly impacted healthcare communications throughout the region. This article describes the impacts, lessons learned, strengths, and challenges faced by two professionals with different perspectives of the Nashville healthcare system.
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ASPR TRACIE. (2021). Managing the Storm After the Storm: Healthcare in TX Recovers from Severe Winter Weather.
Michael Wargo (HCA Healthcare), Scott Cormier (Medxcel), and Toni Carnie (HCA Houston Healthcare Tomball) share how a rare winter storm, extreme cold, and unplanned power outages affected utilities--particularly water and water pressure--in healthcare facilities throughout Texas. This summary highlights issues that will benefit from additional mitigation and preparedness activities as extreme weather incidents increase in frequency.
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ASPR TRACIE. (2023). Crisis in Mississippi: The Emergency Management and Hospital Response to the City of Jackson's Water Outage.
Jim Craig (MPH, CHEP, CHSP, CPM), Senior Deputy with the Mississippi State Department of Health, and Dr. Damon A. Darsey (MD, FAEMS), an Acute Care Consultant with Franciscan Missionaries of Our Lady Health System, share their experiences during the 2022 floods and water outage that impacted the City of Jackson, Mississippi. Access the recording here: https://files.asprtracie.hhs.gov/documents/healthcare-preparedness-series-jackson-water-crisis-response.pdf
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ASPR TRACIE. (2023). No-Notice Health Care Facility Water Loss: HCA Houston Healthcare Tomball's Experience.
Winter Storm Uri brought about sub-zero temperatures and caused extended losses of power and water to over 4.3 million residents in Texas, in structures built to repel rather than hold heat. In March 2023, Jake Marshall (Senior Director of Enterprise Emergency Operations, HCA Healthcare) and Toni Carnie, Safety Officer and Emergency Management Coordinator (HCA Houston Healthcare Tomball) shared their lessons learned as part of an ASPR TRACIE Speaker Series from the event from one facility’s perspective and how they have incorporated them as their system continues to recover. Access the recording here: https://files.asprtracie.hhs.gov/documents/hca-water-pressure-loss-uri-speaker-series-ppt.pdf
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ASPR TRACIE. (2023). Sudden Water Loss and Actionable Considerations.
Jake Marshall (Senior Director of Enterprise Emergency Operations, HCA Healthcare) and Toni Carnie (Safety Officer & Emergency Management Coordinator, HCA Houston Healthcare Tomball) discuss healthcare facility water loss considerations and how their healthcare system to responded to and recovered from Winter Storm Uri.
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ASPR TRACIE. (2023). The Hurricane Ian Experience at Lee Health: Wreckage, Resilience, and Recovery.
More than 150 direct and indirect deaths and over $112 billion in damage have been attributed to 2022’s Hurricane Ian, which made landfall in southwestern Florida as a Category 4 storm. Dave Kistel (Vice President and Chief Facilities Executive at Lee Health) met with ASPR TRACIE and described how the hospital system prepared for, responded to, and recovered from Hurricane Ian, which caused $12 million in damage to Lee Health facilities. Access the recording here: https://files.asprtracie.hhs.gov/documents/hurricane-ian-lee-health-wreckage-resilience-recovery.pdf
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Barkemeyer, B. (2006). Practicing Neonatology in a Blackout: The University Hospital NICU in the Midst of Hurricane Katrina: Caring for Children Without Power or Water. (Abstract only.) Pediatrics. 117(Suppl. 4):S369 -S374.
The author recounts the challenges associated with providing care in a university hospital’s neonatal intensive care unit before, during, and after Hurricane Katrina made landfall.
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* California Hospital Association. (n.d.). Loss of Utilities/Services. (Accessed 11/10/2023.)
This webpage includes links to many resources related to healthcare facilities preparing for and responding to utility outages. There are links to presentations, tools categorized by utility system, best practices, and lessons learned.
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Cote, E. (2021). Case Study: Generator Failure During Power Outage following Hurricane Isaias Underscores Heightened Risk to Patients in Single Generator Facilities.
This article provides a timeline of events and lists lessons learned and promising practices based on a hurricane-related power outage at a skilled nursing facility.
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Cote, E. and Flannery, J. (2017). Roadmap to Resiliency: A Publication from the Healthcare Leadership Initiative on Maintenance of Power. American Society for Healthcare Engineering.
The authors review lessons learned from health care facilities that experienced utility outages, guide readers on assessing emergency power system vulnerabilities, provide an overview of best practices (including collaboration and information sharing). A section on advanced technologies and two case studies are also included.
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Deng, X., Friedman, S., Ryan, I., et al. (2022). The Independent and Synergistic Impacts of Power Outages and Floods on Hospital Admissions for Multiple Diseases. (Abstract only.) The Science of the Total Environment.
The authors examined the effects of power outages and floods in New York State from 2022-2018 and found that health risks increased regardless of whether events occurred separately or simultaneously. For outages and floods combined, immediate increases in risk were observed for chronic respiratory diseases; delayed effects were found on cardiovascular diseases and respiratory infections. The authors concluded that improvements to the power system could significantly reduce the burden on hospitals during and after floods.
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* Do, V., McBrien, H., Flores, N., et al. (2023). Spatiotemporal Distribution of Power Outages with Climate Events and Social Vulnerability in the USA. Nature Communications. 14. .
The authors reviewed power outages from 2018–2020, and found "an average of 520 million customer-hours total without power annually across 2447 US counties (73.7% of the US population)." Longer outages were more likely to occur in northeastern, southern, and Appalachian counties, while counties in Arkansas, Louisiana, and Michigan experienced both frequent 8+ hour outages and higher social vulnerability and prevalence of electricity-dependent durable medical equipment use. Considerations for disaster preparedness and response are included.
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Dominianni, C., Lane, K., Johnson, S., et al. (2018). Health Impacts of Citywide and Localized Power Outages in New York City. Environmental Health Perspectives. 126(6):067003.
The authors identified power outages in New York City between 1999 and 2006 to understand how they affected respiratory and renal disease hospitalizations and all-cause mortality. They found associations between these outcomes and power outages for some events. The results emphasize the importance of resilient electricity grids for health, especially as climate change creates more extreme weather events and power outages may become more common.
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Fink, S. (2013). Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. (Book available for purchase.)
The author details the consequences of Hurricane Katrina on Memorial Hospital in New Orleans. This book—a critical “call to action”—offers learning about the consequences of utilities failures and the importance of incident management, communication, and healthcare coalition connections between hospitals, community emergency medical systems, and emergency management during such incidents and why crisis care processes must be integrated into the incident command system.
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Kearns, R., Wigal, M., Fernandez, A., et al. (2014). The 2012 Derecho: Emergency Medical Services and Hospital Response. (Abstract only.) Prehospital and Disaster Medicine. 29(5): 542-545.
This article describes the use of Emergency Medical Services (EMS) and hospital resources in West Virginia in response to the 2012 derecho that resulted in substantial power outages.
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Klein, K., Rosenthal, M., and Klausner, H. (2005). Blackout 2003: Preparedness and Lessons Learned from the Perspectives of Four Hospitals. Prehospital and Disaster Medicine. 20(5):343-49.
The authors reviewed after-action reports from four hospitals that experienced loss of power (and in two cities, water supply). They found that many issues landing or keeping patients in the hospital were social/resource rather than medical, which is consistent with more recent disasters (e.g., Hurricane Sandy). They also list 17 specific planning considerations for healthcare facilities to incorporate.
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Klinger, C., Landeg, O., and Murray, V. (2014). Power Outages, Extreme Events and Health: A Systematic Review of the Literature from 2011-2012.
The authors identified 20 articles that examined the effects of power outages on health. Table 5 highlights the impacts by category (e.g., hospital, healthcare, community, and public health infrastructure).
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Melnychuk, E., Sallade, T., and Kraus, C. (2022). Hospitals as Disaster Victims: Lessons not Learned? Journal of the American College of Emergency Physicians Open .
The authors analyzed peer-reviewed literature, grey literature, and news articles and listed the following as barriers to successful disaster response: loss of power, water, heating and ventilation, communications, health information technology, staffing, supplies, safety and security, and structural and non-structural damage. They highlight consistent themes challenging hospitals and remind readers that traditional mitigation strategies still work to bolster resilience.
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Minghella, L. (2013). Be Prepared: Lessons from an Extended Outage of a Hospital's EHR System.
The author shares her experience losing access to her facility's electronic health record system for ten days following a power outage.
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Nates, J. (2004). Combined External and Internal Hospital Disaster: Impact and Response in a Houston Trauma Center Intensive Care Unit. (Abstract only.) Critical Care Medicine. 32(3):686-90.
This case report and literature review examines how a 2001 tropical storm caused flooding in a Houston hospital, leading to loss of electricity, communications systems, running water, and internal transportation. Life sustaining ventilators and monitors became ineffective, however no patients died because of the utility failure; triage and transfers to other facilities were important for this outcome. Battery operated communication systems are important, and key services (e.g., pharmacy, labs, and supply rooms) should be prepared for possible hazards. Contingency plans for water and emergency kits with flashlights and two-way radios should be available.
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Present, D., Clair, J., Belyaev, S., et al. (2005). Effects of the August 2003 Blackout on the New York City Healthcare Delivery System: A Lesson for Disaster Preparedness. (Abstract only.) Critical Care Medicine, 33 (1): S96-S101.
The authors reviewed citywide emergency medical calls for service, emergency department visits, and hospital admissions after the 2003 power failure in New York City. They found a nearly 200% increase in EMS calls for service from respiratory issues in community-based patients with 37 admissions to a single hospital for device failure and note the need for better disaster preparedness planning for facilities and homebound patients.
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Qu, Y., Zhang, W., Ye, B., et al. (2021). Power Outage Mediates the Associations Between Major Storms and Hospital Admission of Chronic Obstructive Pulmonary Disease. BMC Public Health. 21(1):1961.
The authors examined the relationship between power outages and hospital admissions for chronic obstructive pulmonary disease (COPD). They found power outages associated with between a 1.23 to 1.61 higher risk of COPD admissions across lag 0-6 days (significant relationship for two days) and emphasized the importance of having backup electrical systems prepared before major storms to reduce related COPD hospitalization.
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Rodríguez-Madera, S., Varas-Díaz, N., Padilla, M., et al. (2021). The Impact of Hurricane Maria on Puerto Rico's Health System: Post-Disaster Perceptions and Experiences of Health Care Providers and Administrators. Global Health Research and Policy. 6(1):44.
The authors conducted semi-structured interviews with healthcare providers and administrators to understand how the blackout in Puerto Rico after Hurricane Maria in 2017 affected healthcare delivery. The interviews revealed that the power outage and a lack of disaster management plan contributed to a crisis for the island’s healthcare system and the deaths of 3,052 individuals. The results emphasize the importance of having alternative strategies (e.g., grassroots and community initiatives, expanding services by turning a pharmacy into a clinic) for providing healthcare after disasters.
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Shelton, S., Hamm, J., Olatosi, B., and Ory Johnson, R. (2018). Recovery of Surgical Equipment Sterile Processing During a Floodwater Boil Advisory. (Abstract only.) Disaster Medicine and Public Health Preparedness.
The authors of this article discuss the challenges faced in recovering their sterile processing for surgical equipment after floodwater contaminated their public water supply. They provide considerations for recovery plans, such as including a potable water source and a method to connect it to a required location.
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Skarha, J., Gordon, L., Sakib, N., et al. (2021). Association of Power Outage with Mortality and Hospitalizations Among Florida Nursing Home Residents After Hurricane Irma. Jama Health Forum. 2(11).
The authors conducted a retrospective cohort study to understand the impact of power failure on 54,095 nursing home residents after Hurricane Irma in 2017. They found that lack of power after Hurricane Irma was “associated with an increased odds of mortality within 7 days and 30 days.” The increased odds of mortality and hospital utilization illustrate the need to better analyze the specific risks and encourage preparedness and regulation to close the gaps.
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Sonchrant, C., Mills, P., Zubkoff, L., et al. (2021). Power Failures During Surgery: A 2000-2019 Review of Reported Events in the Veterans Health Administration. (Abstract only.) Journal of Patient Safety. 17(8): e815-e820.
The authors studied how power failures affected surgical outcomes in Veterans Health Administration facilities between 2000 and 2019. They found that while rare, power outages were in some cases associated with major patient harm. The safety events resulted mostly from generator delay, equipment reboot delay, and equipment backup power failure. The authors recommend disaster preparedness and increased focus on communication during outages to reduce harm.
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St. Dominic's Hospital. (2022). 2022 Jackson Water Crisis Response Summary.
This short article describes how the lessons incorporated by staff at St. Dominic's Hospital after Hurricane Katrina helped mitigate risks to the hospital's well-fed water system. These improvements and the support provided to hospital staff (e.g., providing showers, bottled waters, and other supplies) helped ensure that the hospital was able to continue to provide patient care and maintain operations during the 2022 Pearl River flooding event.
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Tonn, G., Guikema, S., Ferreira, C., and Quiring, S. (2016). Hurricane Isaac: A Longitudinal Analysis of Storm Characteristics and Power Outage Risk. (Abstract only.) Risk Analysis. 36(10): 1936-1947.
The authors collected and analyzed hourly power data outage for Louisiana and examined the correlations between outages and storm conditions (wind, rainfall, and storm surge). In the case of Hurricane Isaac, the authors found that wind speed, precipitation, and previous outages had a stronger relationship with outages (storm surge had a weaker relationship, even in areas where storm surge was significant).
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* U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2019). The Department of Health and Human Services emPOWER Program: emPOWERing Communities Through New Practical Applications, Training, Informational Resources, Toolkits, Maps, and Virtual Assistants.
The first speaker provided an overview of emPOWER and highlighted new data, tools, and resources. Subsequent speakers (from Los Angeles County and the Virginia Department of Health) shared their experiences using the tool and how patients (including those with electrical dependent DME such as ventilators or oxygen concentrators could be contacted/assisted.
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Vetter, A., Harman, R., Stamper, M., et al. (2020). Preparing for Total Power Failure in the Operating Room. Nurse Anesthesiology.
The authors simulated power failure in the operating room (OR) and tested the battery life of equipment to improve healthcare staff decision making ability during a total power failure in the OR. The authors recommend emergency managers and the anesthesia team develop a site and equipment-specific protocol to prepare for power outage in the OR, since battery life will vary based on the type of equipment used at the facility.
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Vugrin, E.D., Verzi, S.J., Finley, P.D., et al. (2015). Modeling Evacuation of a Hospital without Electric Power. (Abstract only.) Prehospital and Disaster Medicine. 30(3):279-87.
The authors of this report describe a modeling case study of the 2001 evacuation of the Memorial Hermann Hospital in Houston, Texas. They used a model designed to track cascading events following loss of infrastructure services and to identify the staff, resources, and operational adaptations required to sustain patient care and/or conduct an evacuation.
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Plans, Tools, and Templates

ASPR TRACIE. (2018). ASPR TRACIE Technical Assistance: Generator Fuel Calculators.
In response to a request for technical assistance regarding fuel needed to power generators, the ASPR TRACIE Team conducted a search of existing calculators or calculation charts. Please note that all of these calculators or charts require the facility to know what the size of the generator and load at which it is operating. ASPR TRACIE does not endorse any particular vendor or commercial third-party listed here.
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ASPR TRACIE. (2023). Utility Failures in Health Care Toolkit.
Utility failures are a major concern for health care and may cause substantial harm to patients, staff, and facilities. Threats include infrastructure damage due to natural disasters and other incidents, planned outages to relieve stress on services or prevent other hazards, and malicious acts such as physical and cyber sabotage. It is also important to note the cascading effects a failure of one utility may have on others; more than one utility may fail simultaneously or sequentially. This suite of tip sheets can help health care facility managers and emergency planners identify issues to consider when planning for and responding to various types of utility failures.
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California Department of Public Health (CDPH) and the California Association of Health Facilities (CAHF). (2017). NHICS: Nursing Home Incident Command System.
This resource includes information on the nursing home incident command system (NHICS), which can be used by facilities regardless of size or resident care capabilities, and is intended to assist with their emergency planning and response efforts for all hazards. Links to the NHICS guidebook, forms, response guides, Job Action Sheets (JAS), and training are included.
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California Emergency Medical Services Authority. (2017). Incident Planning Guide: Utility Failure.
This document includes a series of questions to guide hospitals in planning for utility failures associated with systems such as power, water, heating, ventilation, air conditioning, medical air, vacuum, or medical gases.
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* California Hospital Association. (n.d.). Loss of Utilities/Services. (Accessed 11/10/2023.)
This webpage includes links to many resources related to healthcare facilities preparing for and responding to utility outages. There are links to presentations, tools categorized by utility system, best practices, and lessons learned.
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Centers for Disease Control and Prevention and American Water Works Association. (2019). Emergency Water Supply Planning Guide for Hospitals and Health Care Facilities.
This comprehensive document provides a four-step process for the development of a hospital emergency water supply plan and includes tips for assembling the right planning team, performing a water use audit, analyzing alternatives, and developing and exercising the plan. It is also available in Spanish: https://www.cdc.gov/water-emergency/media/pdfs/19_302124-EWSP-GUIDE-SPANISH.pdf.
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  • Rodney Merritt Onsite Water Management can prevent Hospital water outages.
    9/23/2020 2:27:59 PM
Environmental Protection Agency. (2021). Incident Action Checklist - Power Outages.
This website provides information on power and water utility failures, including a case study of a utility company preparing for power loss due to Hurricane Florence in 2018. The site also includes three checklists for healthcare organizations preparing for, responding to, and recovering from power outages.
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Healthcare & Public Health Sector Coordinating Councils. (n.d.). Planning for Power Outages: A Guide for Hospitals and Healthcare Facilities. (Accessed 11/10/2023.) U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This checklist can help emergency planners prepare for and respond to power outages in their facilities.
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HHS emPOWER Program. (2024). HHS emPOWER Map.
The HHS emPOWER Map provides monthly de-identified totals of Medicare claims submitted for one or more of the fourteen types of life-maintaining or saving electricity-dependent durable medical and assistive equipment (DME) and certain implanted electricity-dependent cardiac devices, at the national, state, territory, county, and ZIP Code levels. Users have the ability to create unique aggregations by geography and export the data, as well as the ability to access historical HHS emPOWER Map datasets for further analysis. When combined with real-time severe weather and hazard maps, the HHS emPOWER Map gives communities the power to anticipate, plan for, and address the needs of this population prior to, during, and after an incident, emergency, or disaster.
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Los Angeles County Emergency Medical Services Agency. (2023). Los Angeles County Healthcare Facility: Emergency Power Resilience Playbook.
This playbook highlights best practices in and protocols for safeguarding emergency health care facility power. Information is provided in four phases (Vulnerability Assessment, System Fortification And Mitigation Planning, Rapid Emergency Power Threat Response, and Post Disaster Recovery) and appendices include checklists, job action sheets, and articles and information that can help others create similar playbooks.
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MedStar Washington Hospital Center. (2018). Emergency Operations Plan: Central Sterilization System Outage. (Contact ASPR TRACIE for access to this document.)
This document provides a framework for the Central Sterilization staff and Hospital Incident Management Team to follow when the hospital’s system becomes inoperable due to power failure, water outage or contamination, equipment failure, limited staffing, or if the system is expected to be out of service for longer than two hours.
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  • Alex Lichtenstein Is it possible to have this attachment uploaded as a resource? I am unable to find it via the search mechanism. Thank you!
    6/5/2019 3:38:20 PM
MITRE Corporation. (2023). RISC Toolkit 2.0.
The Risk Identification and Site Criticality (RISC) Toolkit is an objective, data-driven all-hazards risk assessment that can be used by public and private organizations within the Healthcare and Public Health Sector to inform emergency preparedness planning, risk management activities, and resource investments with a focus on security and infrastructure protection. The RISC Toolkit provides owners/operators in the HPH Sector with standards-based evaluation criteria. It can be utilized by a wide variety of HPH stakeholders including but not limited to hospitals, long-term care facilities, community health centers, health care coalitions, and public health agencies.
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  • Tony Barker Great tool that has very effective resource links. Makes the HVA process evidence based and provides an excellent format for use. Thank you to the development team!
    12/12/2018 12:56:37 PM
Rural Health Information Hub. (n.d.). Marshall Fire Power Outage Impacts San Luis Valley Health Regional Medical Center. (Accessed 5/17/2023.)
This case study provides an overview of the Marshall Fire on a regional medical center. The authors cover success factors, barriers, and lessons learned and how the facility has incorporated those lessons.
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Stymiest, D. (2008). Taking Care of Business – How Hospital Electrical Shutdowns Can Facilitate Emergency Management.
The author shares a comprehensive approach to managing hospital electrical power shutdowns in light of the increasing complexity of hospital infrastructures and operational constraints. He illustrates how using an electrical "shutdown" as a pre-planned and scheduled exercise can help train staff; sample shutdown resources are included in the appendices.
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Agencies and Organizations

Administration for Strategic Preparedness and Response. HHS emPOWER Program Platform. U.S. Department of Health and Human Services.
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California Association of Health Facilities. Utility Failure.
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California Hospital Association. Loss of Utilities/Services.
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Centers for Disease Control and Prevention. Water Resources for Environmental Health Programs.
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This ASPR TRACIE Topic Collection was comprehensively reviewed in May 2023 by the following subject matter experts (SMEs) (listed alphabetically): Eric Alberts, CEM, CHS-V, FPEM, FPEM-HC, CDP-1, CHPP, CHEP, SEM, CFRP, FABCHS, Emergency Preparedness Manager, Orlando Health, Inc.; Scott Aronson, MS, President + Lead Strategist, Global Readiness Partners; Samuel J. Boyle, MCP, DIS, Program Manager Business Continuity, Emergency Management & Business Continuity, Northwestern Medicine; Scott Cormier, Vice President, Emergency Management, EC, & Safety; Gabrielle Bryant, Risk Analyst, National Risk Management Center, Cybersecurity and Infrastructure Security Agency; Eric Cote, Project Director, Powered for Patients; John Hick, MD, Hennepin Healthcare; Dave Kistel, Vice President and Chief Facilities Executive, Lee Health; Mary Russell,  EdD MSN, Healthcare Emergency Response Coalition, Palm Beach County Florida; Dave Stymiest, PE, CHFM, CHSP, FASHE, Senior Consultant, Smith Seckman Reid, Inc.; and Charles Sweat, Jr., MD, MPH, Healthcare and Public Health Sector Liaison, Stakeholder Engagement Division | SRMA Governance, Cybersecurity and Infrastructure Security Agency.

It was comprehensively reviewed in January 2017 by the following: Eric Alberts, CEM, CHS-V, FPEM, FPEM-HC, CDP-1, CHPP, CHEP, SEM, CFRP, FABCHS, Emergency Preparedness Manager, Orlando Health, Inc.; Julie Bulson, DNP, MPA, RN, NE-BC, Director, Emergency Preparedness, Spectrum Health; Kristen Finne, Program Manager, HHS emPOWER Initiative, Senior Policy Analyst, HHS/ASPR/OPP/Division of Healthcare System Policy; Michael Gurnick, Chair, Ashland Branch, Massachusetts Medical Reserve Corps, Region 4A and NACCHO MRC Workgroup; John Hick, MD, HHS ASPR and Hennepin County Medical Center; Brad Learn, Emergency Preparedness Coordinator, Kentucky Hospital Association; and Mary Russell, EdD, MSN, Emergency Services, Boca Raton Regional Hospital. 

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