Evacuation is considered a protective action. It’s a great strategy when all goes well and people get out of harm’s way before it reaches the evacuated facility. Of course, one of the assumptions for success is that you have adequate time and resources to accomplish the mission. It’s very easy to misjudge one or both factors.
I recall one day sitting in my office in downtown Portland. There was a storm system approaching the area and it was packing wind gusts over 100 mph. The Mayor thought it would be a great idea to shut down official government offices and recommend other employers follow suit let people go home early before lunch. I worked for the State and certainly could have left but I chose to remain at work and watch this unfold from my window.
I had a splendid view of several of the bridges that crossed the Willamette river that commuters would be taking. I watched as traffic built as people took the Mayor’s advice to leave early. In no time at all traffic on the bridges was backed up, just like normal rush hour traffic at 5 pm. The winds started within the hour and I watched the bridges swaying, packed with commuters. All the Mayor had done was succeed in moving rush hour traffic so that people were now trapped in the height of the wind gusts. My office was perfectly safe and I continued to work and filed this away as a lesson on evacuation don’ts.
“Evacuation is an option to be considered when there is a perception of risk if staff, visitors and patients remain where they are. But evacuation is not without risk.”
Without adequate vehicles, staff, planning and organization, traffic control and even fuel, evacuation routes can become parking lots in community-wide events. Hurricane Rita directly killed seven people, but twenty-three patients from a nursing home evacuating from the hurricane were killed when the bus carrying them caught fire.
Lesson to learn–use evacuation wisely– understand the risks and options. The other factor that comes into play when evacuation of a hospital is considered is the fact that hospitalized patients will always be better in a hospital than out of a hospital. There is a reason they were admitted. Taking them from a place where you have control over the environment of care and subjecting them to the activities associated with evacuation adds additional risk.
If evacuation is a last resort, what are some options?
One might be to use vertical evacuation. This can be up or down depending upon the threat. For example, a flash flood may require you move patients up one or more floors. A small but contained fire on an upper floor may have you considering moving patients down several floors. In the photo above, Motoyoshi Hospital in Japan had the bottom floor flooded by a tsunami (you can see the watermark on the building) and a vertical evacuation took place. Complete evacuation was not an option due to the wave arrive in less than an hour after a massive earthquake.
Horizontal evacuation may work when a disruption to service occurs in one location and movement laterally solves the problem. Both vertical and horizontal might be combined to relocate a population to an unimpacted area of the facility or another building on the healthcare organization campus.
Shelter-in-place or defend-in-place is an option to consider when the threat is external to your facility and can be kept out. An example would be a hazardous chemical plume moving towards your facility. Closing windows and shutting down the HVAC system will prevent outside air from penetrating the buildings. This can result in untenable conditions over time in extremely warm conditions. This strategy has a better chance of working under such conditions if the organization has pre-planned ahead. A series of misting fans such as used on the sidelines of most college and NFL games in the summer do a wonderful job of cooling people down.
Another option is to buy some time or isolate the facility from the hazard. Civil unrest in a community requires positive control of access to the facility grounds by funneling all ingress traffic through one controlled checkpoint. In the case of a flood event, sandbags could be placed to divert water away from the facility. Adding resources may be another way to avoid having to leave the facility. Any hospital that loses water service is in danger of requiring evacuation if water delivery cannot be restored. Pre-planning with vendors to provide large tank trucks, pumps and temporary water systems can mean the difference between staying semi-comfortably and needing to evacuate.
One other option that may be better than trying to evacuate without enough time or resources is to alter the standards of care. This would best be done in an incremental fashion as necessary and does carry some risk which should be discussed among the C-Suite, practitioners and your ethics committee.
Pre-planning can help by looking at your patient populations and determining before an event the best location for relocating a population. For example, if you need to evacuate your behavior health unit you should know the next best location for meeting this patient population’s needs. Arbitrarily moving them to another floor when a better location farther away better meets their needs should be known ahead of time.
Your facility should have an Evacuation Annex in your Emergency Operations Plan. Training and exercises of this plan, including functional components are critical to ensuring the best possible patient outcomes and upholding the reputation of your organization.
Some really good considerations for thinking about hospital evacuation. I have been involved in evacuations of rest homes and considering hospital evacuations in events.
I think the best thing to think about in these cases is to think what your plan would be. Depending on what the event is it may be appropriate to evac the critical patients if you have appropriate lead time. A general plan is a good place to start that has the flexibility to deal with the situation at hand. The most important thing to remember with medical emergency services is that they will have to manage a patient surge in the short term and recover and move to a preventative phase post event for diseases and other preventable injuries.
Thanks for your thoughts
Steffan Cavill-Fowler
Your comment about lead time is interesting. I have seen very few plans with the exception of hurricane preparedness where timelines and activities are spelled-out. For example. It is much easier to evacuation a nursing home population when the flood waters are projected at 12 hours away versus the floodwaters are 12″ deep on the first floor of the same facility. Having clear cut objective triggers for action is necessary.
Hospital evacuation is a frightening prospect. Some hospitals have done it very well in the case of slow onset disasters such as hurricanes where one has some time before it strikes. Other times with no warning, such as an earthquake some hospitals have done it better than others. As you point out an Evacuation Annex in the EOP is essential. What alternative care facilities would be available and agreed upon? What transportation assets are needed? How to handle medication requirements and medical records, staffing, sheets, pillows and blankets, communications etc. all need to be worked out in advance and then employees taught the procedure. A number of products to aid evacuation of the sick are available and should be acquired pre-need.
John Hoyle
I agree 100% John that pre-planning and exercising lets an organization build a realistic evacuation program. It’s better to find out it takes 12 hours to evacuate your entire facility based on realistic resources and operational challenges than assume you can do it in 4.
Thank you for thinking ahead for preparedness.
Your insights are good to help seriously start the dialogue, to think of getting ready for the “unplanned” hazardous threats and events. Of course, the Emergency Operations Plan should be tailored to each facility, but also according to the expected events. It might be more complex to plan due to the non exhaustive list of hazards and threats.
This may sound a bit crude, but it bothers me when I see professionals and organizations caught with their pants down for a predictable problem. It makes no sense to me why you don’t expend the energy up front to be prepared to accomplish the mission, maintain your reputation and get back to normal operations as soon as possible.
Successful disaster preparedness starts at the top. For certain there must be a “organizational approach” to planning and there will be many external resources, outlying agencies and private sector providers that will need to be brought into the planning process. But for anyone thinking that a “bottom up” or operations based planning project is preferable…I recommend the NY TImes Bestseller about one hospital evacuation during Katrina – “5 Days at Memorial” by Sherri Fink. Without an evacuation plan that is Management led, the outcome of any hospital evacuation could be truly disastrous.
Great comments Robin and they dovetail in nicely with a post I am writing now on mass casualty mismanagement.