In the hours before Hurricane Sandy hit New York last year, the country’s oldest public hospital thought it was ready. Even if Bellevue Hospital’s power and water were cut, it had emergency generators on the 13th floor, well above the flood plain. Its four 55,000-gallon water tanks were perched safely on the roof.

But when the storm came ashore on that October night, the surge swamped the hospital’s basement, which housed its electrical switches and water pumps. Within a few hours, all but one of its generators failed. By the next night, the water pipes ran dry. Rising floodwaters had drowned the pumps. Two days later, deteriorating conditions forced hospital administrators to evacuate patients. No one died, and “they were lucky,” says Dan Hanfling, a national expert on hospital disaster planning.

It’s not clear how many Sacramento hospitals would fare better. In a catastrophic flood, one or more city hospitals would need to evacuate because they aren’t equipped to stay open till help arrives. But some experts think disaster strategies that rely on closing down instead of “sheltering in place” put the city’s health care services and patients at greater risk.

MOST SACRAMENTO HOSPITALS ARE AT RISK IN A FLOOD

The region’s nightmare flood scenario could be the failure of the Folsom Dam. If it happened, hundreds of thousands of cubic feet of water would cascade down the American River, quickly overtopping levees. The city would have eight hours to evacuate, according to a 2008 report by the city’s Office of Emergency Services.

With flood events hitting the lower Sacramento and northern delta regions every three years, on average, since 1955, the failure of local levees is a more likely scenario. Climate change could worsen that statistic, as more extreme storms are expected to increase water runoff to streams and rivers during the winter months, according to the city’s draft Climate Action Plan.

Three of Sacramento’s seven acute-care hospitals — Sutter General, Methodist Hospital and Kaiser Permanente’s South Sacramento Medical Center — lie in the floodplain, according to the Federal Emergency Management Agency’s flood maps. That means there’s a 1-percent chance rising water will reach them in any given year. Those three, plus Mercy General Hospital, also lie in the levee protection zone and could be affected by a levee break, according to the state Department of Water Resources. The remaining three hospitals — UC Davis Medical Center, Shriners Hospital for Children and Kaiser’s Sacramento Medical Center — are in safer spots and outside both the floodplain and protection zone. But they still could face power and water cutoffs given their proximity to vulnerable areas.

If a flood hits, city hospitals should receive help from their county, the state and the federal government, but that will take time to arrive. That’s why the Joint Commission, the national accrediting body for hospitals, recommends that hospitals be able to stay open during a disaster for four full days.

To shelter in place during that interim, what hospitals need most are functioning backup generators and enough water. “A hospital can muddle along with a short-handed staff and limited supplies for days, but it cannot function without power,” Arthur Kellerman, a national expert on hospital preparedness from the Rand Corp., testified to Congress in July.

Those looking for information about hospitals’ flood readiness have one place to turn — hospitals themselves. The Joint Commission doesn’t release the “hazard vulnerability analyses” that hospitals review and update annually, but five of the seven hospitals contacted for this story provided information on their flood readiness.

KEEPING THE LIGHTS ON AND THE WATER RUNNING

Those five facilities all reported that they’re prepared for a normal power outage since they have emergency backup generators — but not all have their equipment above ground, and some may not have enough fuel for four days. At Kaiser Permanente, Hurricane Sandy prompted a review of risks for existing and planned hospitals, says spokesperson Edwin Garcia. So although Kaiser’s two centers store generators underground, they’re raising them above ground by the end of this year. Just as important, the two centers keep enough fuel on hand to run the generators for a full four days.

Sutter General put its below-ground generators in an encapsulated vault, says Emergency Preparedness Director Loni Howard. That container will keep out water, but Howard was not sure for how long. In the event of a flood high enough to take out the generators, the hospital would need to evacuate, she says.

Because the UC Davis Medical Center is on higher ground, its generators are well above the floodplain, says Emergency Preparedness Coordinator Glynis Foulk. If power goes out, the hospital keeps 18 hours of fuel on hand to run them, far short of what the hospital would need for four days. But the likelihood of the center’s primary and backup power sources (natural gas and electric) both going down at the same time is low, Foulk says. If it did happen and the outage was expected to outlast the fuel supply for the generators, hospital administrators would have to decide whether and when to evacuate.

Likewise, Shriners Hospital sits high, so its backup generators shouldn’t be impacted by rising water. But the hospital didn’t respond to questions about how much fuel it keeps on hand to run them.

Four of the five facilities say they’re well set to wait out a cutoff of city water. UC Davis has two on-site groundwater wells of its own plus a stockpile of bottled water to provide three liters per person per day for four days. Sutter General has four days’ worth of water stored in tanks located in a parking garage above the floodplain. Kaiser’s Garcia says its two hospitals also keep enough emergency water on hand to last four days. Shriners’ A.J. Johnson, chair of the hospital’s emergency preparedness committee, says the hospital keeps a backup supply of water but didn’t specify how long it would last.

Four of the five hospitals also report having evacuation plans that can get patients out quickly and safely. Howard says Sutter General can evacuate its patients in two to six hours if conditions demand, though she’d prefer to have more time. Shriners didn’t respond to a question about its evacuation plan.

The other two hospitals, Methodist and Mercy General, didn’t respond to any questions about flood preparedness. San Francisco-based Dignity Health, which operates both, instead emailed a brief statement noting that, “We have emergency operations plans for different types of disasters, including response to flood and sheltering in place.”

EVACUATION VS. SHELTERING

Experts differ on whether a good evacuation plan is enough. The Joint Commission’s George Mills says that if a hospital isn’t set up to shelter in place for four days, a sound evacuation system can anchor its disaster planning. When a killer tornado hit the 9-story St. John’s Regional Medical Center in Joplin, Mo. in May 2011, its well-trained staff got all 183 patients out in 90 minutes with no injuries, Mills says.

But Hanfling says even a good plan for moving patients can’t substitute for staying open. Following Hurricane Sandy, for example, New York City’s health commissioner told The New York Times that there were “definitely risks to patients from evacuations.”

Hospitals that empty out also impact the rest of the health care system, Hanfling says. “The ripple effects from the closure of Bellevue and New York University Langone were huge,” he says. Other hospitals had to add shifts, convert lobbies and offices into space for patients, and even buy additional beds at a local furniture store, according to the Times. In Sacramento, hospitals that close would likely send a wave of patients to UC Davis Medical Center, since it’s above the floodplain. That potential surge, Foulk says, is the center’s primary concern about its ability to shelter in place for four days.

National leaders have long worried about hospitals’ ability to ride out a storm. After Hurricane Katrina, the Joint Commission itself issued new requirements designed to keep hospitals open during a disaster, including suggesting that hospitals move generators and other sensitive equipment out of their basements when planning new construction. And Kellerman told Reuters last November that he’d “been asking hospitals to look at their own survivability” after disasters, and “I just can’t get it on their radar screens.” (A Rand spokesperson said Kellerman wasn’t available for comment because he was moving to another organization.)

But retrofitting hospitals is expensive. If generators are moved above ground, for example, state regulations require that they be anchored to protect them in the event of earthquakes, even in relatively low-risk areas like Sacramento, says Roger Richter of the California Hospital Association. For urban hospitals, construction and retrofitting costs have been rising and now stand at about $2 million per bed, he adds.

Hanfling favors more public/private funding partnerships and bonding to finance retrofitting that can help hospitals ride out disasters. He also suggests that facilities make changes a little at a time to avoid huge one-time costs. “Mitigation activities are expensive,” says Hanfling, “but closing or losing a hospital costs even more.”