External factors impacting hospital evacuations caused by Hurricane Rita: the role of situational awareness

Hospitals as disaster victims: Lessons not learned?

OBJECTIVE

Hospitals are a key component to disaster response but are susceptible to the effects of disasters as well, including infrastructure damage that disrupts patient care. These events offer an opportunity for evaluation and improvement of preparedness and response efforts when hospitals are affected directly by a disaster. The objective of this structured review was to evaluate the existing literature on hospitals as disaster victims.

METHODS

A structured and scoping review of peer-reviewed literature, gray literature, and news reports related to hospitals as disaster victims was completed to identify and analyze themes and lessons observed from disasters in which hospitals are victims, to aid in future emergency operations planning and disaster response.

RESULTS

The literature search and secondary search of referenes identified 366 records in English. A variety of common barriers to successful disaster response include loss of power, water, heating and ventilation, communications, health information technology, staffing, supplies, safety and security, and structural and non-structural damage.

CONCLUSIONS

There are common weaknesses in disaster preparedness that we can learn from and account for in future planning with the aim of improving resilience in the face of future disasters.

California NICU disaster preparedness

OBJECTIVE

NICU patients are disproportionately affected by any disaster due to their vulnerability and highly specialized care needs that require a multitude of resources. Research in disaster preparedness and its effect on NICU patients is limited.

STUDY DESIGN

From March to May 2018, NICUs across California participated in a survey designed to assess their preparedness for a disaster.

RESULTS

Of the 84 responding units, 99% were urban, 73% were nonprofit, and 65% were community NICUs. As for NICU participation in hospital training exercises for disaster preparedness, 10% did not participate in annual drills, 44% did once a year, 36% did twice a year, and 10% did more than two times per year.

CONCLUSION

We showed that many NICUs had redundant systems in place and plans for various disasters; however, there is not consistent participation by NICUs in hospital training exercises for disaster preparedness.

Assessment of Risks Posed to VAD Patients During Disasters

Ventricular assist devices (VADs) are an Advanced Life Support for patients with heart failure. These patients are particularly vulnerable in the event of a disaster. A hazard vulnerability analysis (HVA) was conducted to determine areas of susceptibility for these patients. Lack of electrical power, limited access to medications and anticoagulation, dehydration, extreme temperature and weather environments, conditions which predispose to infection, and evacuation transport are all identified circumstances that place these patients at an increased risk for harm and death. Future preparations in disaster planning are needed to address and mitigate these risks. Davis KJ , O'Shea G , Beach M . Assessment of risks posed to VAD patients during disasters. Prehosp Disaster Med. 2017;32(4):457-461.

The Development of an Evacuation Protocol for Patients with Ventricular Assist Devices During a Disaster

Introduction Health care providers are on the forefront of delivering care and allocating resources during a disaster; however, very few are adequately trained to respond in these situations. Furthermore, there is a void in the literature regarding the specific care needs of patients with ventricular assist devices (VADs) in a disaster setting. This project aimed to develop an evidenced-based protocol to aid health care providers during the evacuation of patients with VADs during a disaster.

METHODS

This is a qualitative study that used expert review, tabletop discussion, and a survey of health care professionals to develop and evaluate an evacuation protocol. The protocol was revised after each stage of review in order to reach a consensus document.

RESULTS

The project concluded with the finalization of a protocol which addresses evacuation and patient triage, and also includes an algorithm to determine which staff members should be evacuated with patients, transportation resources, evacuation documentation, and items patients need during evacuation. The protocol also addressed steps to be taken in the event that evacuation efforts fail and how to manage outpatient VAD patients seeking assistance.

CONCLUSIONS

This protocol provides guidance for the care of VAD patients in the event of a disaster and evacuation. Protocols such as this address difficult scenarios and should be created prior to a disaster to assist staff in making difficult decisions. These documents should be created using multi-disciplinary feedback via the consensus model as well as the Institute of Medicine (IOM; National Academy of Medicine; Washington, DC USA) "Crisis Standards of Care." Davis KJ , Suyama J , Lingler J , Beach M . The development of an evacuation protocol for patients with ventricular assist devices during a disaster. Prehosp Disaster Med. 2017;32(3):333-338.

Evacuate or Shelter-in-place? The Role of Corporate Memory and Political Environment in Hospital-evacuation Decision Making

PROBLEM

Hospital-evacuation decisions are rarely straightforward in protracted advance-warning events. Previous work provides little insight into the decision-making process around evacuation. This study was conducted to identify factors that most heavily influenced the decisions to evacuate the US Department of Veterans Affairs (VA) New York Harbor Healthcare System's (NYHHS; New York USA) Manhattan Campus before Hurricane Irene in 2011 and before Superstorm Sandy in 2012.

METHODS

Semi-structured interviews with 11 senior leaders were conducted on the processes and factors that influenced the evacuation decisions prior to each event.

RESULTS

The most influential factor in the decision to evacuate the Manhattan Campus before Hurricane Irene was New York City's (NYC's) hospital-evacuation mandate. As a federal facility, the Manhattan VA medical center (VAMC) was exempt from the city's order, but decision makers felt compelled to comply. In the case of Superstorm Sandy, corporate memory of a similar 1992 storm that crippled the Manhattan facility drove the decision to evacuate before the storm hit.

CONCLUSIONS

Results suggest that hospital-evacuation decisions are confounded by political considerations and are influenced by past disaster experience. Greater shared situational awareness among at-risk hospitals, along with a more coordinated approach to evacuation decision making, could reduce pressure on hospitals to make these high-stakes decisions. Systematic mechanisms for collecting, documenting, and sharing lessons learned from past disasters are sorely needed at the institutional, local, and national levels.

Evacuation of a neonatal intensive care unit in a disaster: lessons from Hurricane Sandy

NICU patients are among those potentially most vulnerable to the effects of natural or man-made disaster on a medical center. The published data on evacuations of NICU patients in the setting of disaster are sparse. In October of 2012, New York University Langone Medical Center was evacuated during Hurricane Sandy in the setting of a power outage secondary to a coastal surge. In this setting, 21 neonates were safely evacuated from the medical center's NICU to receiving hospitals within New York City in a span of 4.5 hours. Using data recorded during the evacuation and from staff debriefings, we describe the challenges faced and lessons learned during both the power outage and vertical evacuation. From our experience, we identify several elements that are important to the functioning of an NICU in a disaster or to an evacuation that may be incorporated into future NICU-focused disaster planning. These include a clear command structure, backups (personnel, communication, medical information, and equipment), establishing situational awareness, regional coordination, and flexibility as well as special attention to families and to the availability of neonatal transport resources.

External factors impacting hospital evacuations caused by Hurricane Rita: the role of situational awareness

INTRODUCTION

The 2005 Gulf Coast hurricane season was one of the most costly and deadly in US history. Hurricane Rita stressed hospitals and led to multiple, simultaneous evacuations. This study systematically identified community factors associated with patient movement out of seven hospitals evacuated during Hurricane Rita.

METHODS

This study represents the second of two systematic, observational, and retrospective investigations of seven acute care hospitals that reported off-site evacuations due to Hurricane Rita. Participants from each hospital included decision makers that comprised the Incident Management Team (IMT). Investigators applied a standardized interview process designed to assess evacuation factors related to external situational awareness of community activities during facility evacuation due to hurricanes. The measured outcomes were responses to 95 questions within six sections of the survey instrument.

RESULTS

Investigators identified two factors that significantly impacted hospital IMT decision making: (1) incident characteristics affecting a facility's internal resources and challenges; and (2) incident characteristics affecting a facility's external evacuation activities. This article summarizes the latter and reports the following critical decision making points: (1) Emergency Operations Plans (EOP) were activated an average of 85 hours (3 days, 13 hours) prior to Hurricane Rita's landfall; (2) the decision to evacuate the hospital was made an average of 30 hours (1 day, 6 hours) from activation of the EOP; and (3) the implementation of the evacuation process took an average of 22 hours. Coordination of patient evacuations was most complicated by transportation deficits (the most significant of the 11 identified problem areas) and a lack of situational awareness of community response activities. All evacuation activities and subsequent evacuation times were negatively impacted by an overall lack of understanding on the part of hospital staff and the IMT regarding how to identify and coordinate with community resources.

CONCLUSION

Hospital evacuation requires coordinated processes and resources, including situational awareness that reflects the condition of the community as a result of the incident. Successful hospital evacuation decision making is influenced by community-wide situational awareness and transportation deficits. Planning with the community to create realistic EOPs that accurately reflect available resources and protocols is critical to informing hospital decision making during a crisis. Knowledge of these factors could improve decision making and evacuation practices, potentially reducing evacuation times in future hurricanes.