Public Health Emergency Preparedness

Chapter 1. Introduction

This document is designed to provide hospital evacuation decision teamsⁱⁱ—herein abbreviated as "decision teams"—with organized and systematic guidance on how to consider the different factors involved in hospital evacuation either in advance of an event, based on some degree of forewarning, or following a disaster, if needed. The Hospital Evacuation Decision Guide is intended to supplement hospital emergency plans, which focus on the specifics of how the hospital will shelterin- place or carry out an evacuation once the decision to shelter-in-place or evacuate has been made. Many individual hospital evacuation emergency plans lack specific guidance on how to make that critical decision, including what factors to consider and for how long the decision may be safely deferred.

This Hospital Evacuation Decision Guide is not a "cookbook" and specifically does not offer a formulaic approach to evacuation decisionmaking. No single formula or algorithm could possibly capture all of the nuances involved in the decision or the myriad different event scenarios that may determine the need for evacuation. In some situations, the decision to evacuate is clear and obvious, such as a fire or major infrastructure damage that places patients and staff at risk. No decision guide is needed for these situations. This Hospital Evacuation Decision Guide is intended to provide assistance in those instances when the decision is not clear—when the uncertainty of the event and its aftermath may result in compelling arguments both for and against hospital evacuation.

This Guide does not recommend or present best practices for carrying out an evacuation or for sheltering-in-place during and after a disaster, other than to stress the importance of having comprehensive evacuation and shelter-in-place plans. The reader is referred to other publications for advice on developing and executing evacuation plansⁱⁱⁱ and shelter-in-place plans.^iv

An additional role of this Hospital Evacuation Decision Guide is to assist decision teams in identifying some of the special situations, often overlooked, that may exist in their facility or geographic area and that could affect the decision to evacuate. Identifying these specific considerations, and planning in advance to take them into account during decisionmaking, may better prepare leadership to make an evacuation decision, should the need arise.

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Methodology

An extensive literature search was conducted to identify all relevant material about hospital evacuations and decisionmaking during disasters affecting a single hospital or an entire region. Peerreviewed journals and trade publications, as well as government reports, working papers, and other "gray"literature, were all included in the search.

An in-person meeting of an expert panel was convened in Washington, D.C., in January 2009. Panelists representing appropriate Federal agencies participated, as well as many hospital leaders who had experienced evacuations and researchers who have studied disaster evacuations. In the subsequent months, additional telephone interviews were conducted with experts having a wide array of hospital evacuation experiences (e.g., hurricanes, earthquakes, fires, floods). Finally, a series of meetings were held with disaster planners, as well as medical and facilities experts from Partners Healthcare (Massachusetts General Hospital and Brigham and Women's Hospital) in Boston, Massachusetts. The expert panel also reviewed a draft version of the Guide. A list of panel members is in Appendix A.

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Types of Disasters vs. Reasons for Evacuation

It is important to distinguish the type of event or disaster that could lead a decision team to consider evacuation (e.g., earthquake, flood), as distinct from the ultimate reason for the evacuation (e.g., structural damage, loss of municipal water).

In theory, any of the various types of disasters listed in Table 1 could lead a decision team to consider evacuating patients, either prior to an event or in the aftermath of the event. In this Guide, we distinguish between "Advanced Warning Events"and "No Advanced Warning Events."With Advanced Warning Events, decision teams have time prior to the event to make evacuation decisions. Hurricanes are the most common example of an Advanced Warning Event. With earthquakes, tornadoes, and other instances of No Advanced Warning Events, decisions must often be made very quickly, either in the midst of the disaster or immediately afterward.^v

Table 1. Types of Disasters¹

Natural Hazards	Technological Hazards	Terrorism
Floods Tornadoes Hurricanes Thunderstorms and Lightning Winter Storms and Extreme Cold Extreme Heat Earthquakes Volcanoes Landslide and Debris Flow (Mudslide) Tsunamis Fires Wildfires	Hazardous Materials Incidents Nuclear Power Plants	Explosions Biological Threats Chemical Threats Nuclear Blast Radiological Dispersion Device (RDD)

The type of event precipitating an evacuation is typically well publicized. It is widely known, for example, that several hospitals evacuated their patients in the aftermath of Hurricane Katrina in 2005, and prior to Hurricane Gustav making landfall in 2008. What is less clear is the ultimate reason—or set of circumstances—that prompted many documented evacuations. In the case of the flooding following Hurricane Katrina, New Orleans hospitals evacuated when they lost city water, lost all power, or were unable to ensure the safety of patients and staff in the midst of civil unrest. After careful examination, it is clear that it was not the hurricane or the subsequent flood that caused decision teams to order hospital evacuations but the damage to hospitals and critical infrastructure, as well as problems in the surrounding community.

Table 2 lists some instances of hospital evacuations, the type of disaster that preceded the evacuation, whether (in the case of Advanced Warning Events) decision teams decided to evacuate prior to the event, whether the evacuation took place after the event, and the ultimate reason(s) for the evacuation. Table 2 is intended to be illustrative and not a comprehensive listing of all hospital evacuations. In particular, not shown are the many instances in which decision teams seriously considered evacuating but, in the end, decided not to. Table 2—and, more generally, this Guide—does not address operational aspects of how these evacuations were executed, such as which local, State, or Federal assets were used to evacuate patients.

Table 2 highlights the importance of critical infrastructure, in particular the water supply, in many evacuation decisions.

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Guide Organization

The remainder of this report is organized into three chapters:

• A Pre-Disaster Hospital Self-Assessment is discussed in Chapter 2. The self-assessment should be completed as part of a hospital's disaster preparation and planning efforts. It focuses on critical infrastructure and assets that are of specific concern with respect to evacuation. It is intended to help decision teams identify vulnerabilities that affect the likelihood that a hospital would have to evacuate as well as specific challenges a hospital may face during evacuation, either prior to or in the aftermath of a disaster. The self-assessment and accompanying text also provide assistance in estimating the time required to evacuate patients from the hospital and relocate them to other facilities. Being able to form an accurate estimate of the time required to evacuate is a critical component of the decision to evacuate.
• Pre-event evacuations, an option in the case of Advanced Warning Events, are discussed in Chapter 3. For pre-event evacuations, the self-assessment of vulnerabilities and the scope/scale of the impending event are the key factors to consider. Chapter 3 includes guidance on whether—and when—to preemptively evacuate patients prior to an event, as well as on the accompanying decision regarding the sequence in which patients should be evacuated (i.e., who goes first).
• Chapter 4 addresses post-event evacuations, which could occur either 1) with an Advanced Warning Event in which decision teams decide to shelter-in-place during the event and subsequently realize the need to evacuate, or 2) following a No Advanced Warning Event.

Table 3 is a list of Guide terminology and acronyms.

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ⁱⁱ The "hospital evacuation decision team"—abbreviated in this Guide as "decision team"—denotes the persons in charge of planning for an evacuation well in advance of an incident, as well as the persons who ultimately decide whether to evacuate a hospital during an incident. In reality, the Incident Commander—who is often a senior hospital administrator—would make this decision in conjunction with senior hospital staff and emergency management and response officials if the hospital has activated its Emergency Operations Plan and is operating according to the Hospital Incident Command System (HICS). Developed by the California EMS Authority, HICS is a methodology for using the Incident Command System (ICS) in a hospital environment that is consistent with the National Incident Management System. Within the ICS management framework, the Incident Commander has overall responsibility for managing the incident, which for the purposes of this Guide refers to the event that precipitated a possible evacuation of the hospital.
ⁱⁱⁱ For examples, go to the California Emergency Medical Services Authority's Evacuation Planning Scenario (http://www.emsa.ca.gov/HICS/files/Int_02.pdf [PDF Help]), the New York City Hospital Evacuation Protocol (http://www.nyc.gov/html/doh/downloads/pdf/bhpp/bhpp-hospital-nyctpevac-plan.pdf [PDF Help]), and the California Hospital Association's hospital evacuation template (http://www.calhospitalprepare.org/sites/epbackup.org/files/resources/HospitalEvacuationPlanChecklistCHAv07092008.doc ).
^iv For example, the California Hospital Association's shelter-in-place checklist (http://www.calhospitalprepare.org/sites/epbackup.org/files/resources/CHASIPChecklist030709.doc ).
^v Situations in which a decision team considered evacuating, but ultimately decided not to, are less likely to be documented in the literature; we therefore do not know the true breadth of disaster circumstances that led decision teams to consider evacuation but ultimately decide against it.

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