Public Health Emergency Preparedness

Executive Summary

This Hospital Evacuation Decision Guide is designed to:

• Provide hospital evacuation decision teamsⁱ with organized and systematic guidance on how to consider the many factors that bear on the decision to order an evacuation.
• Assist decision teams in identifying some of the special situations, often overlooked, that may exist in their facility or geographic area that could affect the decision to evacuate.

No single formula or algorithm could possibly capture all of the nuances involved in the decision or the myriad different disaster scenarios that may lead to a hospital evacuation, and this Guide does not offer a formulaic approach to evacuation decisionmaking. Instead, the Guide is intended to supplement hospital emergency plans, which frequently 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 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 critical need for comprehensive plans for both evacuating patients and for sheltering-in-place.

The Guide is based on an extensive literature search; discussions at an expert panel meeting; telephone interviews with experts having hospital evacuation experiences in different types of disasters; and a series of meetings with disaster planners, medical staff, and facilities experts from Partners Healthcare (Massachusetts General Hospital and Brigham and Women's Hospital) in Boston. The technical expert panel (Appendix A) also reviewed a draft version of the Guide.

The Guide includes a pre-disaster hospital self-assessment and discussions of both pre- and post-event evacuation decisionmaking.

Pre-Disaster Hospital Self-Assessment

The Guide contains two tools, which together comprise a Pre-Disaster Self-Assessment, for use as part of the planning process.

• The first, a Pre-Disaster Assessment of Critical Infrastructure, focuses on critical infrastructure vulnerabilities that may affect the likelihood that a hospital would have to evacuate, either prior to or in the aftermath of a disaster. The assessment instrument in the Guide is divided into eight sections: municipal water, steam, electricity, natural gas, boilers/chillers, powered life support equipment, information technology and telecommunications, and security. The focus is on environmental systems (HVAC), water, and electricity because they are critical for hospital operations, and their loss for an extended period invariably triggers a need for evacuation.
• The second, an Evacuation Time Self-Assessment Worksheet, is a framework for estimating the time required to safely evacuate all patients and focuses on a number of factors that affect evacuation time, including: the number of patients, mix of patient acuity, available staff, available exit routes within the hospital, patient transportation requirements, available transportation resources (vehicles and the necessary accompanying staff, equipment, and supplies), entry and egress points at the hospital, road and traffic conditions, and the location of receiving care sites.

Pre-Event Evacuations

Pre-event evacuations are undertaken in advance of an impending disaster, when the hospital structure and surrounding environment are not yet significantly compromised. As the event progresses and conditions deteriorate, the opportunity for a safe evacuation diminishes, and eventually decision teams must decide whether to evacuate the hospital or shelter-in-place. Deciding whether to preemptively evacuate or shelter-in-place requires consideration of two factors:

• The nature of the event, including its expected arrival time, magnitude, area of impact, and duration.
• The anticipated effects on both the hospital and the community, given the nature of the event and the results of the Pre-Disaster Self-Assessment.

The Guide includes a two-part worksheet to help decision teams in this complex set of considerations. The first part focuses on implications of different characteristics of the impending disaster. The second part provides a framework for assessing the anticipated effects of the event on key resources needed to care for patients (water, heat, and electricity), the overall structural integrity of the building, and the surrounding community.

Post-Event Evacuations

Post-event evacuations are carried out after a disaster has caused substantial damage to a hospital or the surrounding community. As soon as possible after the event occurs, building integrity, critical infrastructure, and other environmental factors must be assessed in order to determine whether or not the hospital can continue to provide appropriate medical care to patients or should instead be evacuated. The Guide includes a worksheet to help with a careful assessment of damage to the hospital's water, sewer, electricity, and heating systems, as well as the overall building integrity, to help decision teams decide whether an evacuation should be ordered.

Sequence of Patient Evacuation

After an evacuation is ordered, decision teams must decide the sequence in which patients should be evacuated. The most medically fragile and resource-intensive are usually evacuated first, as soon as appropriate transportation and staff are available. In cases where all patients are in immediate danger and evacuation must be conducted as quickly as possible, the evidence suggests that the most mobile patients should be evacuated first.

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ⁱ The term "hospital evacuation decision team"—abbreviated in this Guide as "decision team"—is used in the Guide to denote 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.

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