Fire isn't an unfamiliar hazard to Pomerado Hospital, a 107-bed acute-care facility in the city of Poway, San Diego County. Having survived the 2003 wildfires that swept through Southern California, the doctors, nurses and administrators at Pomerado Hospital were acutely aware of the threat wildfire presented to their hospital. This threat became a reality when another wildfire hit just four years later.
Keeping heavy smoke out of Pomerado Hospital from the fire that started on Sunday morning, Oct. 21, 2007, was a significant concern. As flames approached within 15 miles of the hospital that evening, the decision was made to open the hospital's command center and establish communication with the San Diego County Emergency Operations Center (EOC).
Although most hospitals plan for taking patients in during a disaster, the exact opposite process confronted Pomerado Hospital. By around 3 a.m. on Monday morning, preplanning for a full-scale hospital evacuation began in earnest, and a collective decision was made by those in the command center to move forward with the evacuation of all patients from the hospital.
Shortly before 8 a.m. on Monday, Oct. 22, Pomerado Hospital began the process of evacuating all 75 in-patients and 14 emergency department (ED) patients, against the backdrop of smoke-filled skies and flames burning in the nearby hillsides.
"We staged our acute patients in the ED, pairing them by two -- one in a wheelchair and one in a gurney -- with a nurse or CNA accompanying each pair of patients while they waited to evacuate," says Joanne Barnett, nurse manager of the ED. "By pairing patients together, we were able to make sure each ambulance was filled before leaving our facility. We evacuated our acute-care patients through our ED, while less acute, ambulatory medical-surgical patients were evacuated out of our hospital's front entrance using buses provided by the local school district."
The 2007 firestorm in San Diego is just one example of the potential disasters we face. As we continue to inhabit high-risk areas and our population densities increase, the threat of disasters with significant consequences to our lives continues to grow. Both natural and human-caused disasters can strike with little notice and overwhelm a community's resources, including emergency medical care. The ensuing response typically brings out the best and worst in a community -- it's a time when heroes emerge and lives are saved, but also a time when pre-existing physical and social vulnerabilities within a community are exacerbated. Thus, being well-versed on the evacuation policies of your local heath-care facilities is a critical component of disaster-response planning.
Health-care Facility Vulnerabilities
Although disasters present significant threats to all aspects of society, experience demonstrates that hospitals and other health-care facilities have unique vulnerabilities. Understanding the highly complex process of evacuation in these settings requires awareness of certain concepts, such as the Hospital Incident Command System (HICS), medical task forces, ambulance strike teams, as well as successful practices utilized by health-care facilities in past evacuations.
A study published in 2004 revealed there were 275 health-care facility evacuations from 1971-1999. Since that study, many more hospitals have been evacuated. In 2001, Tropical Storm Allison flooded the basement of Memorial Hermann Hospital in Houston, resulting in the evacuation of all 540 patients. Twenty-eight hospitals were evacuated during Hurricane Katrina in 2005. Several hospitals and other health-care facilities were evacuated in Southern California during firestorms in 2003 and 2007; in fact, some of those facilities were evacuated during both firestorms.
A variety of hazards, such as earthquakes, hurricanes, floods, fires, hazardous materials, failed utilities, civil unrest and temperature extremes, can lead to health-care facility evacuation. Greater than half of hospital evacuations are caused by incidents originating within the hospital itself. These events often occur with little notice, making it difficult for a facility to prepare adequately for all scenarios.
In the case of hospitals, patients may be in surgery, in intensive care, on ventilators or undergoing any number of procedures when the event requiring the evacuation occurs. Many patients will require more resources than the facility can supply during a disaster.
At the same time, vital equipment may become damaged, inaccessible or otherwise unusable. Direct damage to a health-care facility's structural integrity can immediately compromise the ability to provide patient care, while non-structural conditions arising from a disaster can also require the evacuation and abandonment of a health-care facility.
During the 1994 Northridge, Calif., earthquake, four hospitals suffered structural damage that required their demolition. Structural damage may be obvious and result in immediate evacuations, or in some cases, the damage is noticed only during detailed inspections, resulting in a delayed evacuation. Even when structural damage is nonexistent or minimal, hospitals are still dependent on critical services, such as electricity, running water, sanitation and telecommunications, to function effectively. Loss of these services can create conditions that require a hospital to evacuate.
Rising floodwaters and winds during Hurricane Katrina cut off ground transportation and shut down electricity, telecommunications and sanitation. Riding out the storm was no longer an option at Tulane University Hospital and Clinic inLouisiana. A full-scale evacuation ensued when generators used up emergency fuel, food and water ran in short supply, and the city sewer system started to back up.
Hospitals serve as a key resource in treating victims following a disaster and generally plan toward accepting an influx of patients during times of emergency. The need to "surge," or accommodate a rapid influx of patients, is the result of injured walk-ins, EMS transports and accepting patients from other evacuating facilities. However, when a hospital is presented with its own casualties while trying to deal with an influx of patients, the overwhelming demands can result in critical failure.
Maintaining adequate staffing to provide patient care is challenging during a disaster. Staff may not be able to report for duty if roads are blocked or damaged, or they may be unwilling to leave their own families. Ensuring ongoing staffing requires sufficient resources to rotate staff, and providing necessities, such as meals, hygiene and sanitation, and rest.
Emergency responders, who play a critical role in planning and responding to health-care facilities during a crisis, may experience similar staffing issues, making it difficult to meet the needs of the community.
Command Structures & Teams
Moving patients involves an intensive management of resources and significant preparation. Evacuations benefit from a well-tested model for establishing command and control, communications and resource management.
The HICS, formerly Hospital Emergency Incident Command System (HEICS), is an emergency management system designed to help hospitals operate in a time of crisis. Adapted from the national Incident Command System (ICS), the HICS provides a flexible management system that can contract and expand with the emergency.
The HICS provides a clear chain of command with a manageable scope of responsibility for each position. Like ICS, it also provides a prioritization of tasks and can be used for emergencies from mass casualty incidents to hospital evacuations. Additionally, the HICS utilizes common terminology that integrates with public safety when necessary.
During an emergency EMS benefits from a single point of contact with the evacuating health-care facility. Under HICS, this point of contact is usually the hospital's transportation unit leader, liaison officer or incident commander. The job responsibilities of key positions within the HICS structure are described in Table 1.
The Ambulance Strike Team (AST)/Medical Task Force (MTF) model is a valuable tool in organizing EMS response to hospital evacuations. Additionally, this model provides a predictable interface for health-care facilities. The AST/MTF leader should be familiar with all the positions in the HICS organizational structure. The transportation unit leader at a health-care facility is most likely to interact with the AST/MTF leader and has the responsibility of establishing ambulance off-loading areas for those being received from the community, as well as ambulance loading areas for those being transported from the facility. The transportation unit leader must work closely with the patient tracking officer. The importance of patient tracking cannot be overstated, as experience demonstrates how easily patients can become unaccounted for after a hospital evacuation.
These evacuations require extensive planning and training to effectively integrate EMS and other transport providers with local government, public safety and public health. Although many models exist for EMS during disaster response and health-care facility evacuation, it's imperative that the model utilized takes into account the specific needs of the community. Additionally, it's essential that all entities understand their roles prior to an evacuation to ensure the process is successful and resources are appropriately and effectively deployed.
Accomplishing a health-care facility evacuation during a disaster requires planning for more ambulances and additional transportation resources, while continuing to meet the community demands for 9-1-1 response. In a community-wide crisis, the disaster plan should address the increased demands onEMS resources. During the 2003 Grand Prix fire inCalifornia, 9-1-1 call volume was up 15% on the first day of the fire, increasing to 36% at the peak of the fire.
EMS providers must have a clearly defined role within the response framework and should take the time to understand how their participation in ASTs and MTFs is written into the disaster plan. Other critical components to a successful evacuation include a clearly defined chain of command, an organized reporting system and a method to track patients as they're relocated from facilities to holding areas or destination facilities.
An AST is composed of five ALS ambulances (Type I AST) or five BLS ambulances (Type II AST) accompanied by one strike team leader. By comparison, an MTF is composed of multiple types of resources, such as a combination of ALS and BLS ambulances (or other transport resources with a medically trained responder) with common communications and a single leader.
All AST and MTF members should have basic training in the Incident Command System; FEMA recommends ICS 100, 200 and a basic multi-casualty incident course. Additionally, FEMA recommends that team leaders have at least three years ofEMS experience, some leadership qualifications and have participated in an AST leader course.
The evacuation successes experienced during the 2007 San Diego firestorm were in part attributed to frequent drilling on the response plan and the "high baseline education of the field provider in the AST [model]," according to Travis Kusman, operations manager and PIO for American Medical Response (AMR) San Diego division, who served as the San Diego County EOC Disaster Ambulance Coordinator during the first 32 hours of the firestorm.
Ambulances deployed as part of ASTs and MTFs should be prepared to remain active and on-duty for 12- to 24-hour shifts and self-sufficient for at least 72 hours to minimize the team's impact on strained community resources. Difficulties may arise when crews already on shifts are called to participate with ASTs or MTFs.
Kusman states that although health-care facility evacuations during the 2007 San Diego firestorm were very successful, one of the few difficulties involved ambulances being pulled from regular 12-hour shifts to participate in the strike team, but were not prepared to deploy for 72-hours. This unavoidable difficulty can be mitigated when additional ambulances prepared for 72-hour deployments are added to the resource pool.
Poorly prepared EMS providers create situations where their participation is actually counterproductive to the disaster response. Their presence uses resources intended for the actual disaster victims. Thus, AST and MTF team members should consider stocking a personal 72-hour response kit with clothing, bedding, food, water and some personal effects. Table 2 contains a list of items a responder might include in such a kit.
Logistics are crucial to any disaster plan, especially when ASTs and MTFs are deployed outside of their primary response area. Because of the dynamically changing nature of a disaster, logistical considerations would include the provision of maps, navigation tools and patient destination plans in the event of a communication failure. Equipping field providers with this type of information will ensure a successful evacuation despite changing situations.
The AST and MTF leader must also oversee the needs related to individual team members and supplies. These include personnel quarters, food and water, personal-care items and any safety devices, such as PPE, necessary to provide safety and comfort to the responders working under disaster conditions. A useful resource in planning for staffing and deployment of ASTs and MTFs is FEMA's Web site, which provides a specific list of requirements for AST and MTF organizations.
In summary, disaster plans should actively address how EMS providers assigned to ASTs and MTFs will be able to function independently for as long as required and not drain disaster resources. EMS crews must be prepared to deploy for 12- to 24-hour shifts and have a place where they can return to and rest between shifts. Extra personnel should be kept in reserve and rotated as needed to avoid responder exhaustion. Finally, individual providers may wish to have an emergency plan for their own loved ones, when appropriate, which will assure their own peace of mind and a more distraction-free deployment.
Key Points to Remember
As health-care facilities begin actively preparing for full-scale evacuations, emergency plans should reflect the valuable lessons learned from other facilities. The evacuation experiences of health-care facilities throughout the nation suggest that preplanning, central coordination or management, dependable communications, and a strong working relationship between health-care facilities and EMS are keys to a successful evacuation.
Preplanning is essential to establishing the actual evacuation process, identifying common problems and orienting staff to new roles. Even in the absence of a written and rehearsed plan, the hours leading up to the evacuation should be spent reviewing the strategy, organizing resources and opening a dialogue with the necessary partners to accomplish the evacuation. Drills are invaluable at testing the evacuation process and shouldn't be overlooked; when conducted jointly between health-care facilities andEMS, critical relationships are established before the crisis strikes.
Central coordination or management of the evacuation by an external entity is a critical factor in successful evacuations and becomes increasingly important when multiple hospitals are involved and the disaster is regional in nature. Health-care facility evacuation represents a complex supply-line process in a chaotic environment. Central management can benefit this process by overcoming localized communications failures, actively coordinating limited resources and ensuring efficient deployment of resources to areas of need.
During the 2007 San Diego firestorm, Kusman recalls, "Field paramedic supervisors who weren't assigned to lead a specific AST would go to areas that had been deemed as evacuation areas to do a needs assessment. This was done to more efficiently allocate available AST resources, and what occurred was that many of the groups or areas that could self-evacuate did so. When the field 'scout' paramedic supervisor arrived to do a numbers assessment, they found many of the facilities had already self-evacuated, and the ASTs were able to focus their responses to the other facilities that weren't able to do so."
Communication is an essential tool during disasters. Effective communication starts with knowing the key individuals to contact in the event of a disaster or health-care facility evacuation, and a current contact database of key individuals is indispensable. Multiple methods of communication should be considered in addition to wire and wireless telecommunication infrastructures, as well as provisions for maintaining battery-operated communication devices in the absence of power.
Two-way radios, the Internet, mass notification services, and conference call or outgoing message lines can provide additional methods for coordinating, notifying individuals, recalling staff and providing status updates. Communities with multiple agencies or different communications technologies must address interoperability in both the disaster plan and in practice.
Finally, the importance of patient care records and accurate documentation of patient tracking cannot be underestimated. The separation of patients from their medical records means receiving hospitals won't have knowledge of the patient's condition, medical history or medications, and it can also delay evacuation.
Documentation of patient movement provides an efficient method of census so that no victims are left unaccounted for, and also assists families in reconnecting with loved ones in the aftermath of a disaster. Proper and complete documentation of patient evacuations and patient tracking records can also facilitate a more timely reimbursement of expenses for both hospital and transport agencies.
The evacuation at Pomerado hospital continued throughout the morning, with 14 ED patients evacuated during the first hour, and more than 40 patients evacuated two hours into the evacuation. Barnett says the evacuation went smoothly, in part because of information and coordination offered by the San Diego County EOC. "Shortly after requesting transport resources from the EOC, we had ambulances outside of our doors."
Several other factors contributed to the successful evacuation. Early activation of the Incident CommandCenter and ongoing communication allowed the San Diego County EOC to anticipate the hospital evacuation and stage EMS resources at the Poway Fire Department, about a mile from the hospital.
The EOC coordinated a multitude of transport resources, including ambulances from 9-1-1 agencies and non-9-1-1 agencies, as well as wheelchair vans and buses from school districts. Additionally, the EOC communicated with area hospitals, compiling a list of receiving facilities and available beds made available to Pomerado Hospital and other health-care facilities requiring evacuation.
During this evacuation, choosing a destination for patients was the responsibility of the nurse manager and a paramedic supervisorƒindividuals who could evaluate each patient's acuity by direct observation and determine a destination in the patient's best interest. Highest acuity patients were transported to the closest appropriate facilities to minimize transit time, while more stable patients were transported to outlying hospitals.
By early afternoon, all patients fromPomeradoHospital had been successfully evacuated, moments before the public evacuation order potentially gridlocked roads. No adverse impacts to the patients were reported. In the hours to come, just a few individuals remained atPomeradoHospital to staff the ED and care for any straggling walk-ins or responders needing care.
James F. Goss, MHA, MICP, is program director and lead paramedic instructor for NCTI in Riverside, Calif. He's also assistant professor of emergency medical care at Loma Linda University in Loma Linda, Calif., and a frequent contributor to JEMS.
Ehren B. Ngo, MS, EMT-P, is program director for the bachelor of science degree in emergency medical care at Loma Linda University and serves as the University's disaster operations coordinator. He's also a volunteer for the San Bernardino County Sheriff Search and Rescue, San Gorgonio mountain team.
Lindsey Simpson, BS, EMT-P, is a faculty instructor for the Emergency Medical Care Program at Loma Linda University, and an instructor at the UCLA-Daniel Freeman Paramedic Education Program. She's also a field paramedic for AMR in Ventura, Calif., and a volunteer on the medical team for the Ventura County Sheriff Department Search and Rescue Aviation Unit.
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