ABSTRACT OF THE THESIS

An assessment on deciding to evacuate or shelter in place for hospitals during hurricanes

Hurricanes Katrina and Sandy produced widespread damage and massive disruption to health and medical providers.  The widespread damage caused some hospitals to evacuate and others to shelter-in-place. It is a difficult decision that state, cities, and hospital leadership have to address during uncertain times.  Conducting an evacuation of a hospital is considered to be the last resort (Childers, Mayorga, & Taaffee, 2014).  Evacuations can expose patients to dangerous external conditions that result in unintended consequences that exacerbate the patients’ health (Bjarnadottir, Li, & Stewart, 2011).  The process requires assessing the situation and predictions, understanding capabilities, and identifying vulnerabilities.

This study examines the decision through a comparative analysis of four hospitals, two from Hurricane Katrina, and two from Hurricane Sandy, that made opposing decisions when faced with the same threat.  The study identifies that internal capability and vulnerability assessments to be the driving force behind evacuation decisions.  The hospitals that chose to evacuate prior to the hurricanes making landfall had accurately assessed their capabilities and understood the limitations to their capabilities to care for patients.

Introduction to the Problem

Hospitals provide essential care to millions of Americans every day.  The care provided by hospitals and clinics is essential to the wellbeing of these patients.  The complex health system infrastructure is dependent on continued functionality when emergencies occur.  Hospitals must remain capable of providing services regardless of the emerging threats or disaster that they may face at any giving time.

Hurricanes are complex storms that pose many challenges for communities near the coastal United States.  There are many characteristics of hurricanes that contribute to the overall impact it inflects on communities.  Wind speed, latent heat, combative weather fronts, trade winds, and interaction with land can help shift the severity and path of hurricanes.  The continued development characteristics of hurricane are important because it could dictate the actions that one will take regarding safety.  The increase in intensity may draw leaders to error on the side of taking a more protective stance, or alternatively discount the potential to cause damage when the severity of the storm decreases.

Physical damage to hospitals or disruption of services can lead to detrimental consequences.  It is essential to understand the best course of action for hospitals to take when facing an uncontainable hurricane.  Hospitals have only two main options when facing a hurricane; they can either ride out the storm and shelter in place, or evacuate the hospital to an alternate care facilities located in a safer area.

Statement of the Problem

Hospitals provide critical care to people and are expected to remain fully functional at all times, including during events that disrupt service.  Over seven percent of the United States population has stayed at least one night in a hospital during 2014 (Center for Disease Control, 2016).  This results in over 22 million people that receive vital medical services that required individuals to remain in the care of hospitals overnight.

Hospitals are located where there are sufficient populations that justify the services they provide.  In 2010, 123.3 million people, or 39 percent of the nation’s population lived in counties directly on the shoreline (National Oceanic and Atmospheric Administration, March 2013). Coastal communities are prone to experiencing the devastating impacts from hurricanes.  The annual damage caused by hurricanes in recent years is near $6 billion with the 2004-2005 Atlantic hurricane seasons causing a staggering $150 billion in damages (Bjarnadottir, Li, & Stewart, 2011).

Hospitals face many challenges when ensuring their services remain operational during disruptions.  Hurricanes pose many threats that could influence their ability to remain functioning.  Hospital leadership, based on current models, conducts an assessment based on predictions, to either remain in their facility (shelter-in-place) or evacuate to alternative facilities that reside in a safer location (evacuation).  The decision to evacuate or shelter-in-place in advance of a hurricane is complex and time sensitive based on potential uncertainty (Ricci, Griffin, Heslin, Kranke, & Dobalian, 2015).  If a hospital waits to evacuate, they could endanger patients, staff, and ability to provide continuation of services.  If a hospital chooses to ‘ride out’ the hurricane, they could endanger patients if not adequately prepared to handle potential impacts.  It is vital to assess historic actions taken during hurricanes by hospitals and lessons learned for decisions.

Background of the Study

After devastating disasters, there is often criticism of decisions that were made by those in leadership positions.  It is easy to provide opinions and conduct an after-action that examines actions that were taken during an uncertain time.  The decision to evacuate a hospital has many variables that leadership must consider.  Ultimately, the decision to evacuate hospital should be made to ensure the continued care of patients, safety of staff, and minimizing potential impacts. The decision should not be based the convenience or cost of executing an action.  It is important to look at historic examples and understand the reasoning behind the decisions with the most current information.

Hurricane Katrina and Hurricane Sandy caused widespread damage across Louisiana, Mississippi, New York, New Jersey and Connecticut. Millions were impacted by the two hurricanes ranging from flooding, wind damage, power loss, gas shortages, and disruption to routine essential services (New York City, 2013, Andress, 2009).  These disruptions included impacts on hospitals that faced an increase demand for medical attention by those injured during the hurricanes.  Hospital services must remain operational, either in their original facility, or at an alternate location that is in a safer location.

Purpose Statement

The purpose of this research is to gain insight into opposing decisions made by hospitals when faced with the same threat.  Why did one hospital evacuate and another decide to shelter-in-place when facing the same hurricane?  There are many possible answers to this question and it is important to understand the reasons.  A careful analysis of recent examples provides an opportunity to gain the insight into the possible variables that exist when hospital leadership make their decisions.  Was it a lack of planning?  Lack of logistical support?  Did the underestimate the damage from the hurricane?  It is important to look beyond one example and to gain insight from multiple events from two distinct hurricanes.

LITERATURE REVIEW

Preparedness Activities

Hospitals prepare for many different situations that may affect their capabilities to operate and care for their patients.  The scope and expectations for preparedness activities can come from multiple levels.  Hospital leadership may direct preparedness efforts at an organization level based on leadership concerns, local environment, or previous events.  A comprehensive threat assessment of the hospital service area can motivate these decisions.

Research on hospital preparedness covers a wide span of scenarios and topics.  Little research has focused specifically on preparedness of hospital evacuation.  A study conducted by Jafari, Golmohammadi, and Seyed (2008) focuses on resource management allocation in a fictitious hospital.  The simulation includes a hospital with eight stories that have specific capabilities and levels of care spread across floors.  Patients are categorized as either ambulatory or nonambulatory.  Five processes are applied to a scenario to identify what resource dispatch process results in the most expedient evacuation.  The study concluded that resource allocation using a ‘float pool’ of human services, medical and non-medical, to direct to specific areas reduces the time needed to safely evacuate staff, patients, and guest (Jafari, Golmohammadi, & Seyed, 2008).  The conclusion of the study verifies the importance of resource allocation strategies, but does not address the primary concern related to the effectiveness of evacuation of a hospital compared to sheltering in place.

There are many resources available for hospital preparedness activities related to emergencies.  The United States Department of Health and Human Services (DHHS) has several programs that assists hospitals prepare for emergencies.  The Assistant Secretary for Preparedness and Response (ASPR) manages the Hospital Preparedness Program (HPP).  This program enables health care systems to save lives during emergencies that exceed normal daily capacity (U.S. Department of Health and Human Services, n.d.).  Sixty-two awardees – health department within states, localities, and territories – use health care coalitions (HCCs) as a means of providing support (U.S. Department of Health and Human Services, n.d.).

It is important to understand the definition of what an HCC is and what the benefits are health and medical providers.  DHHS defines a HCC as a group of individual health care and response organizations, emergency management organizations, public health agencies, in a defined geographic location (U.S. Department of Health and Human Services, 2016).  HCCs function as a collaborative group that supports various medical and public health activities in the context of incident command system (ICS) responsibilities.  HCCs are a critical player in developing health care delivery system preparedness and response capabilities.  In 2016, there was a total of 486 HCCs, encompassing 26,271 members, playing an active part in healthcare preparedness activities through the HPP (U.S. Department of Health and Human Services, n.d.).

The history of HPP has shifted its focus and priorities over the history of the program. From 2002 to 2011, the program focused on purchasing equipment.  The equipment purchased during this time allowed for medical personal protection equipment, medical cache supplies, emergency pharmaceutical supplies, generators, durable medical equipment, and communication enhancements.  This phase focused on building capacity and increasing the means to conduct emergency operations related to logistics.

From 2012 to 2016, the program aimed at going past the equipment and focused on promoting health care capabilities through forming HCCs.  The development of HCCs allows member agencies to leverage resources in a collaborative effort by forming geographic partnerships with member agencies involved in health and medical planning.

From 2017 and beyond, the program will focus on operationalizing the HCC for effective response by using their designated geographic area, increased capabilities, and supplies.  This transition compliments the previous two focus areas.  Having the right tools and equipment paired with the right structure and organization allows for the concept of operationalizing during emergencies more manageable.

Federal support is not the only option to coordinate hospital preparedness.  State hospital preparedness activities are directed and coordinated by a state agency.  These agencies work with federal partners and local communities.  The designated agencies have the ability to create and implement their own health and medical preparedness programs that address anything outside the focus of federal programs.  Efforts led by state agencies can fill gaps that are identified by local hazard assessments and better serve hospitals and HCCs within various geographic areas.

States have the ability to require various preparedness requirements through the licensing and oversight.  Requirements are implemented through legislation and/or policy.  The focus of law and policy by states primarily focus on standards of care and operational capability. Emergency preparedness activities and capabilities standards are enforced through hospitals seeking accreditation through various organizations.

Training

Training, related to emergency management, falls under preparedness.  Training helps expand skillsets and maintain capabilities.  Hurricanes can cause widespread damage and create challenging scenarios for medical professionals.  It is important for hospitals to conduct training to expose members to possible situations, testing their capabilities and going beyond routine environments.  Training can occur in many forms to include online course, instructor led, or attending a seminar or conference.  Doctors, nurses, and many medical professions are required to take continuing education to maintain their certifications (Baioni, et al., July 2013).  The benefit expands beyond the individual and crosses into the organization.

Little research has been conducted on the benefits of training related to hospital evacuation.  A study conducted by Williams, Nocera, and Casteel looked at the effectiveness of training pertaining to disasters (Williams, Nocera, & Casteel, September 2008).  The study covers multiple scenarios for hospital emergencies including mass casualty and bioterrorism.  The primary goal of the study was to assess the effectiveness of deliver means for emergency training, online and lecture.  The conclusion of study found that available evidence was insufficient to determine if emergency training for health care providers was effective in improving knowledge and skills in emergency response (Williams, Nocera, & Casteel, September 2008).  The study cited a large span of topics related to emergency preparedness as being an obstacle to confirm the benefit of training.  However, hospital evacuation was not included and assessed during the study.

In the absence of research related to training on evacuations within hospitals, many beneficial training opportunities are available to hospitals to support emergency management efforts.  The online trainings and webinars are an excellent tool to be used by hospitals to create an internal training program aimed towards identified threats and hazards.

The Disaster Information Management Research Center, provided by DHHS and the National Institute of Health, has collected 11,970 trainings, webinars, and resources for health and medical professionals.  This searchable depository helps pinpoint topics that are relevant to a hospital regarding specifics scenarios that are prudent to the preparedness phase.  A search of “hospital evacuation” resulted in thirty-two resources, trainings, and webinars that could be used to support a cumulative training package for various segment of staff with the hospital.

The Federal Emergency Management Agency (FEMA), has many health, medical, and hospital specific trainings.  FEMA has made generic course specific to health and medical professionals.  For instance, Incident Command Systems (ICS) 100 is a course that many involved in emergency management take to understand the structure and principles of emergency response.  FEMA has taken the generic course and tailored the content to hospitals and healthcare.  Introduction to the ICS for Healthcare/Hospitals (IS-100.HCb) is approximately three hours and is a self-paced, online training aimed towards physicians, nurses, and staff working in materials/resource management, security/safety, laboratory, radiology, and inter-facility transport (Federal Emergency Management Agency, 2015).

There are many national institutes and organizations that provide trainings in many forms.  A national leader in providing hospital emergency planning training is the Center for Emergency Preparedness and Disaster Response at Yale New Haven Health.  Course cover a range of topics to include the Joint Commission/Centers for Medicaid and Medicare Services (CMS), National Incident Management System (NIMS), Occupational Safety and Health Administration (OSHA), special populations, radiation, biological/infectious diseases, behavioral health, mass fatality, and healthcare compliance (Center for Emergency Preparedness and Disaster Response at Yale New Haven Health).  The trainings are targeted to hospital, healthcare and public health workers.

The Center for Emergency Preparedness and Disaster Response offers two trainings specific to evacuation.  Emergency Management (EM) 150 – Introduction to Evacuations examines the approaches to evacuation, recognizes events that cause the need to evacuate, and discusses concerns related to the monumental task (Center for Emergency Preparedness and Disaster Response at Yale New Haven Health).  The second course is EM 151 – Patient Movement During Evacuations.  This course identifies specific challenges when conducting evacuation and provide guidance on staffing to patient ratios, proper movement techniques, and transportation options (Center for Emergency Preparedness and Disaster Response at Yale New Haven Health).  Both courses are available online and take sixty minutes to complete.  The online courses provide a great introduction to topics and can be followed up with exercises to increase efficiency.

Exercises

Exercises allow for plans and concepts to be operationalized to gauge their effectiveness. Taking ideas, plans, processes, and training to fruition by simulating probably scenarios allows for immediate validation and feedback.  This allows for technical and managerial skill development while letting the individual know how they are likely to react to stressors (Sinclair, Doyle, Johnston, & Paton, 2012).  Lessons learned observed by the participant and observers will allow successes and challenged to be captured and adjustments made pre-disaster.

Little research has been conducted on exercises for hurricane evacuations.  Research conducted on exercises within hospitals and medical centers focus on specific events, and not the overall program.  Hunter, Yang, Petrie, and Aragon (2012) look at the framework from a California state-wide exercise to gage participants’ feedback to create a new framework to be implemented in the preparedness phase (Hunter, Yang, Michael Petrie, & Aragón, 2012).  The exercise scenario generated mass casualties from an improvised explosive device and did not include any evacuation.

Regardless of the event and actions, the study found that an overarching problem was the inter-organizational communications using the existing framework (Hunter, Yang, Michael Petrie, & Aragón, 2012).  Surveys reached 35 local health departments (LHDs), 24 local emergency medical services (EMS) agencies, 121 hospitals, and 5 Regional Disaster Medical and Health Coordinators/Specialists (RDMHC) (Hunter, Yang, Michael Petrie, & Aragón, 2012).  The conclusion of the study found the complexity of overlapping authoritative organizations contributed to confusion in communications.  Additional factors include staff that perform emergency duties as a secondary function and operating in emergency operations centers with other agencies (Hunter, Yang, Michael Petrie, & Aragón, 2012).  Hunter, et al. (2012) recommend that work should be completed in the preparedness phase to help address the inter-organization communication issues by heling clarify expected and actual organizational roles, responsibilities, and resource capacities in the medical and public health structure (Hunter, Yang, Michael Petrie, & Aragón, 2012).

An overview and after action review was conducted of a hospital evacuation exercise at Cincinnati Children’s Hospital.  The exercise lasted one hour and was conducted prior to any surgeries to minimize the impact on scheduled patients.  The pediatric level I trauma center with 525 beds and more than 12,000 employees had conducted training and exercises in segmented departments, but had never conducted a hospital wide evacuation exercise (Baioni, Gneuhs, Dickman, Weber, Hueneman, Timm. July 2013).  The exercise was performed in a control environment that allowed hospital staff to demonstrate department plans and procedures in a collaborative manner with situation injects.

Evacuation Guidance

Guidance is the advice or information intended to resolve a problem or difficulty. Guidance originates from a source that has extensive knowledge on the topic and provides advice as an authority figure or organization.  Hospital evacuations are complex and involves many stakeholders.  The identification of roles and responsibilities, methods of communication, and pre-identified actions drives the efforts for producing plans and procedures consistent with standards from authoritative experts.  Guidance is intended to be a tool to help implement standard accepted practices and procedures in a manner that can be duplicated with ease.

No research has been conducted related to the effectiveness of hospital evacuation guidance.  Evacuation guidance exists from many authorities to include the Agency for Healthcare Research and Quality (AHRQ) within the U.S. DHHS.  The AHRQ is charged with supporting research designed to improve the quality of healthcare, reduce its cost, address patient safety and medical errors, and broaden access to essential services (Agency for Healthcare Research and Quality, 2010).  The Hospital Evacuation Decision Guide focuses on evacuation efforts into three time frames; pre-disaster, pre-event, and post-event.  Each has unique areas and concerns that required consideration and collectively build to make a comprehensive approach to create a plan.

The pre-disaster self-assessment guides the user through examining critical infrastructure. This includes water, steam, natural gas, electricity, boilers, life support equipment, health information technology, telecommunications, and security (Agency for Healthcare Research and Quality, 2010).  Understanding how critical infrastructure functions within the hospital is critical to keep the vital services operating during an emergency.  Each identified function requires redundancy or alternative methods to ensure care of patients remain uninterrupted.  Addressing an issues or concern in the pre-disaster phase of the assessment allows for procedures and protocols to be established prior to an incident.

The guide also addresses estimating evacuation time.  There are many factors to developing a realistic evacuation time that allows for plans to be developed.  A key factor is understanding the number of patients and patient acuity mix.  Identifying what patients are ambulatory and not, while understanding that specific numbers fluctuate on a daily basis. Knowing specific patient information leading up to a potential disaster, such as a hurricane, allows for generic plans to be updated with current census information.

Staffing levels can cause major implications during hospital evacuations. The correct staff, with the right skills, is needed at both the hospital conducting evacuation and the receiving care provider.  Timing of operations and understanding what staff is needed prior to the disaster is crucial.  Hurricanes are notice events, meaning precursory information about the threat will be known in advance.  Hospital leadership has the ability to conduct staffing adjustments and make operation decisions based on current forecasts.  A pre-disaster self-assessment should consider personnel policies, potential staffing shortfalls, and alternate staffing options for the most critical functions (Agency for Healthcare Research and Quality, 2010).  Staff should be notified as early as possible to ensure they can plan for their family and personal affairs to ensure they can perform their duties when required.

Hospital evacuation require specialized resources for transportation.  The Hospital Evacuation Decision Guide suggests conducting a Self-Assessment Worksheet that includes an estimate of the number, or percentage, of patients requiring special transportation to other facilities (Agency for Healthcare Research and Quality, 2010).  Transportation resources go beyond the vehicles and include the required accompanying staff, equipment, and supplies. Arrangements made with transportation providers prior to the disaster increases the likelihood that they will be available when needed.  Hospitals should ensure that multiple providers are identified to ensure that evacuation operations can continue if a provider is unable to provide the requested transportation resources.

Estimating the time needed to evacuate a hospital can be challenging.  The Hospital Evacuation Decision Guide provides four possible approaches.  The first approach is to find a comparable hospital that has evacuated before under similar circumstances and use their time as the estimated total for planning.  The second approach is to conduct an evacuation tabletop exercise that mirrors a full scale evacuation.  Using the estimated time generated from the exercise provides a realistic estimate without conducting a large full-scale exercise.  The third approach is a computer model that simulates a scenario with various factors that computes an estimated evacuation time.  Lastly, a calculation can be made from planning how many round trips are needed to the alternate care facility to evacuate the patients in care.  Multiplying the time required by the number of patients and adding additional time for transporting patients to the staging area can total an estimated evacuation time.  This approach allows the hospital to calculate the total time working backwards.

The second time phase to the Hospital Evacuation Decision Guide covers the pre-event evacuation actions.  A pre-event evacuation is appropriate when hospital leadership believe the hurricane may cause damage resulting in unacceptable risk to patients and staff, or when the damage from the storm will result in conditions that would make future evacuation impossible or dangerous (Agency for Healthcare Research and Quality, 2010).  Gauging risk and potential dangers for future disasters is not easy.  Hospital leadership have to carefully conduct assessments and reassess the current forecast and projections to develop a timeline for decisions. The wait-and-reassess option is time limited.  As the conditions deteriorate, patients will not be able to be evacuated safely due to hurricane force winds or impassable roads.

Timing is a key component for leadership to decide to evacuate or shelter-in-place. The AHRQ, review of literature, and expert interviews, all confirm that the most common decision during the approach of an Advance Warning Event is to shelter-in-place (Agency for Healthcare Research and Quality, 2010).  Recent hurricanes have shown that evacuation of hospitals prior to hurricane landfall is more common than historic examples (Agency for Healthcare Research and Quality, 2010).  Local emergency management and government leadership should be used to help verify potential impact and can help coordinate support for either evacuation or shelter-in-place.

Post-event evacuation occurs with no-notice events or after impacts from disasters result in more damage that projected.  Hospitals should prioritize patients when conducting evacuation with the most resource-intensive patients to be the first leave (Agency for Healthcare Research and Quality, 2010).  Additional challenges could occur to constraints on resources, ambulance, and accessibility to alternative care facilities.

The U.S. DHHS is not the only agency to produce hospital evacuation guidance. Guidance can come from other federal, state, and local government agencies, non-profit, and professional organization.  The Florida Department of Health produced the Hospital Emergency Evacuation Toolkit, supporting hospitals within Florida to create evacuations plan.  However, the toolkit does not provide a complete set of procedures that can be used during an evacuation. Preparedness, planning, training, and exercises are needed to support the development of an evacuation plan and program that benefits the hospital and ensures the continuing care for patients.

The Hospital Emergency Evacuation Toolkit, produced at the state level, provides guidance for a smaller audience.  National guidance is written to be generic enough that allows for adaptation to various geographic areas.  State and local guidance can identify unique issues and concerns that national guidance is not able to.  State and local laws can be included to create a better resource for providers to use.

The toolkit covers many areas that the U.S. DHHS guidance does, but at a more detailed manner.  The Introduction section provides and overview of state and federal authorities, evacuation triggers, ethical issues, and possible evacuation timeline.  The guidance provides useful information on trigger points, a decision point that requires action within a defined time to ensure the safe execution when facing damaging impacts from a threat (Florida Department of Health, 2011).  Pre-identifying trigger points in the preparedness phase reduces possible disagreement between hospital leadership neglecting to make decisions.

Addressing ethics in hospital evacuation is important.  It is not an easy decision for leadership to make.  The decision to shelter-in-place verses evacuate is a life or death decision (Florida Department of Health, 2011).  The decision to evacuate is considered from an ethical, medical, and economic viewpoint with the goal of ensure the best care for patients and ensuring safety of staff.

The scope of evacuation section includes preparedness elements.  This section covers types of evacuation, creating a comprehensive plan, hospital incident command system, notification, and communication with state and local authorities.  This section identifies multiple options related to evacuation.  Evacuation does not exclusively refer to a full emptying of a hospital.  If only only one building on a hospital campus is damaged, there may be only a partial evacuation to an alternate care site or undamaged building on campus.

The coordination with stakeholders is extremely important.  A hospital should coordinate their plans with local and state health partners.  Coordination with partners allow for an understanding of what actions will be taken prior to an event occurring.  Local and state health departments knowing the alternate care location for hospitals before an evacuation occurs allow for better coordination of support and resources.

Section three covers facility issues.  A hospital can contain one or many buildings making up a campus.  Coordinating multiple buildings into a comprehensive evacuation plan can be challenging.  Each building should have an individual plan that correlates to the comprehensive plan for the hospital campus.  The identification of primary and alternate staging areas is needed to ensure staff are aware of their locations.  Pre-determined routes from buildings to staging areas allow for emergency planners to use realistic evacuation time estimate and determine appropriate resources that are needed.

Patient and staff considerations is section four.  Creating a system for prioritizing patients prior to a disaster will help expedite the evacuation process.  Categorizing patients into triage levels identifies what resources, both equipment and personnel, are needed using a strategic process.  The categorization of patients into triage levels should be done prior to evacuation and not once the evacuation process has started.

There are multiple strategies on the prioritization of patients and the sequence that they should be evacuated.  Table 1, Evacuation triage level and evacuation order, shows two methods for evacuations once patients are categorized.  The reversed start priority begins evacuating patients that need minimal assistance to be transported to the staging area.  These patients are coded green because of the minimal support needed to transport.  Once all patients that were marked green are moved to the staging area, the next triage level is yellow, patients that require some assistance, possible one to two staff, to be transported to the staging area.  The last triage level to be evacuated are the patients that require the most support and are coded red. These patients require two to three staff because of their inability to move themselves or having a mobility injury.  The traditional start priority evacuation is the exact opposite of reversed start priority.  The traditional start priority starts with the most complex patients first and moves toward the most transportable patients being the last to evacuate.

Table 1 – Evacuation triage level and evacuation order