Topic Collection Cover Page

Healthcare Facility Evacuation/Sheltering
Topic Collection
September 27, 2022

Topic Collection: Healthcare Facility Evacuation/Sheltering

Past and recent disasters have illustrated the need for healthcare facilities to have solid evacuation and shelter-in-place plans for patients and staff. The COVID-19 pandemic added a new variable to incorporate into planning efforts. Plans must incorporate pre-established community incident command and management structures as well as lessons learned from co-occurring disasters, mutual aid, and patient transfer and equitable loading efforts over the past several years. In some circumstances, sheltering in place protocols may also be implemented as a necessary means of protecting facility occupants (patients, staff, and visitors) from external or internal threats (e.g., security threats or chemical, biological or nuclear events). Recent incidents including civil disturbance in communities across the country have required healthcare facility implementation of lock down procedures/access controls. These factors also should be considered and addressed when planning for sheltering in place. For more information, visit ASPR TRACIE’s Active Shooter and Explosives and Workplace Violence Topic Collections. Information on Federal Patient Movement is included in the Patient Movement and Tracking Topic Collection.

This ASPR TRACIE Topic Collection was refreshed in August 2022. The resources in this Collection include plans, guidelines, lessons learned from recent events, and promising practices that can help healthcare facility staff develop evacuation and sheltering plans, and facilitate their training and exercise development.

Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category.

Must Reads


California Hospital Association. (n.d.). Hospital Repopulation after Evacuation: Guidelines and Checklist. (Accessed 7/11/2022.)
The California Hospital Association worked with subject matter experts to identify best practices and regulatory agency requirements that have to be taken into account when repopulating after full or partial evacuation of general acute care hospital inpatient buildings. The guide includes a checklist that can be completed electronically or printed and filled out by hand.
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Dosa, D., Hyer, K., Thomas, K., et al. (2012). To Evacuate or Shelter In Place: Implications of Universal Hurricane Evacuation Policies on Nursing Home Residents. Journal of the American Medical Directors Association. 13(2): 190 e1-7.
The objective of this study was to examine the differential morbidity/mortality associated with evacuation versus sheltering in place for nursing home residents exposed to four hurricanes in the Gulf region. The authors discuss their methodology and results of the study. Among residents exposed to hurricanes, evacuation significantly exacerbated subsequent morbidity/mortality.
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Downey, E.L., Andress, K., and Schultz, C.H. (2013). Initial Management of Hospital Evacuations Caused by Hurricane Rita: A Systematic Investigation. (Abstract only.) Prehospital and Disaster Medicine. 28(3):257-63.
The authors conducted a retrospective study on seven hospitals that either evacuated or sheltered in place during and after Hurricane Rita. They found that hospitals should plan for continuous patient arrival even during evacuation, and certain shortages (e.g., staff and food) when sheltering in place.
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The author of this article describes the evacuating/ sheltering experiences of several New York City hospitals during Hurricane Sandy, and how hospital executives and the New York State Health Commissioner made evacuation decisions.
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Haggerty, E. (2013). When Bellevue Had to Evacuate Its Criminally Insane. Bedford and Bowery.
The author addresses having to evacuate patients with serious behavioral health issues, and highlights experiences and challenges faced by Bellevue Hospital in the aftermath of Hurricane Sandy.
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Harvard School of Public Health Emergency Preparedness and Response Exercise Program, and Emergency Preparedness Bureau at the Massachusetts Department of Public Health. (2014). MDPH Hospital Evacuation Toolkit.
This toolkit is designed to assist hospitals as they review and update their plans annually for partial or full evacuation. It provides multiple guidance documents (e.g., staffing, assembly point, emergency receiver), and a hospital evacuation plan checklist.
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McGinty, M., Burke, T., Barnett, D., et al. (2016). Hospital Evacuation and Shelter-in-Place: Who Is Responsible for Decision-Making? (Abstract only.) Disaster Medicine and Public Health Preparedness. 10(3):320-324.
The authors of this article conducted semi-structured interviews with decision makers to understand reasoning behind making evacuation or shelter-in-place decisions during Hurricane Sandy (2012). They found that perceived authority among hospital executives and government officials was necessary for the decision maker to order evacuation, and there is a risk of inaction when government officials and hospital executives both view themselves as having this authority.
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Pandolfo, J. (2014). Comprehensive Planning for Emergency Evacuation of Healthcare Facilities. Patient Safety and Quality Healthcare.
The author provides a to-do list for developing a healthcare evacuation plan and notes that creating a plan will ensure patient safety during an emergency and increase buy-in from the staff and management.
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Zane, R., Biddinger, P., Hassol, A., et al. (2010). Hospital Evacuation Decision Guide. Agency for Healthcare Research and Quality.
This guide was created to assist hospitals in evaluating the factors that influence the decision to evacuate a facility, and can serve as a supplement to the hospital’s emergency plan. It includes a Pre-Disaster Hospital Self-Assessment and discussions of both pre- and post-event evacuation decision-making.
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Education and Training


Minnesota Department of Health. (n.d.). Healthcare Facility Training Matrix for Sheltering, Relocation, and Evacuation. (Accessed 7/11/2022.)
This PowerPoint presentation explains how the Minnesota Department of Health trains staff in sheltering, relocation, and evacuation. Staff are placed into one of three categories (all staff, operations, or command staff) and the training is tailored to these groups. A sheltering, relocating, and evacuation decision tree is also included.
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This PowerPoint presentation highlights a jurisdiction's lessons learned from recent events that necessitated hospital evacuation. It includes strategies for decision making, patient triage, tracking patients and residents, and planning. It also includes definitions of the terms associated with hospital evacuation and a printable slide of "disaster tags" that can be placed on a patient's belongings, wrists, and door.
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* Natarajan, N. (2013). Coastal Storm Planning, the Healthcare Facility Evacuation Center (HEC), and Patient Tracking. New York State Department of Health, Office of Health Emergency Preparedness.
This presentation provides a history of the Healthcare Facility Evacuation Center (HEC) and describes the main objectives of the HEC. It also identifies challenges and describes the events that took place when New York hospitals evacuated during Hurricanes Irene and Sandy.
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This video was developed to be an educational tool for staff training on emergency preparedness specific to long-term care facilities. The scenario follows staff as they deal with a major storm that causes a week-long power outage. The video covers topics including preparedness, sheltering in place, and evacuation.
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Evaluation and Studies


Adalja, A.A., Watson, M., Bouri, N., et al. (2014). Absorbing Citywide Patient Surge during Hurricane Sandy: A Case Study in Accommodating Multiple Hospital Evacuations. Annals of Emergency Medicine. 64(1):66-73.
The authors of this study conducted interviews with 71 key staff from four hospitals in New York City after Hurricane Sandy to identify medical surge strategies used. More specifically, these hospitals received patients from evacuated healthcare facilities during and after the hurricane. Results indicated that there were improvement opportunities in the following areas: prolonged increased patient volume, an increase in the number of methadone and dialysis patients, ability to absorb displaced staff, the challenges associated with nursing homes that have evacuated and shelters that have already reached capacity, and reimbursements for transferred patients.
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Childers, A. (2010). Prioritizing Patients for Emergency Evacuation from a Healthcare Facility. Clemson University TigerPrints. All Dissertations. Paper 595.
This dissertation addresses the complex ethical decision-making process associated with hospital evacuation. The goal of this research is to develop a decision framework for prioritizing patient evacuations, where unique classifications of patient health, rates of evacuation, and survivability all impact the choice.
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* Dosa, D., Hyer, K., Thomas, K., et al. (2012). To Evacuate or Shelter In Place: Implications of Universal Hurricane Evacuation Policies on Nursing Home Residents. Journal of the American Medical Directors Association. 13(2): 190 e1-7.
The objective of this study was to examine the differential morbidity/mortality associated with evacuation versus sheltering in place for nursing home residents exposed to four hurricanes in the Gulf region. The authors discuss their methodology and results of the study. Among residents exposed to hurricanes, evacuation significantly exacerbated subsequent morbidity/mortality.
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Downey, E.L., Andress, K., and Schultz, C.H. (2013). External Factors Impacting Hospital Evacuations Caused by Hurricane Rita: The Role of Situational Awareness. (Abstract only.) Prehospital and Disaster Medicine. 28(3): 264-271.
The authors examined the effect situational awareness had on hospitals' decision to evacuate or shelter in place during and after Hurricane Rita. They found that incident management teams reported two main factors that guided decisions: (1) the effect of the incident on the facility's internal resources and challenges; and (2) how the incident characteristics would affect external evacuation activities.
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Downey, E.L., Andress, K., and Schultz, C.H. (2013). Initial Management of Hospital Evacuations Caused by Hurricane Rita: A Systematic Investigation. (Abstract only.) Prehospital and Disaster Medicine. 28(3):257-63.
The authors conducted a retrospective study on seven hospitals that either evacuated or sheltered in place during and after Hurricane Rita. They found that hospitals should plan for continuous patient arrival even during evacuation, and certain shortages (e.g., staff and food) when sheltering in place.
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* Femino, M., Young, S., and Smith, V. (2013). Hospital-Based Emergency Preparedness: Evacuation of the Neonatal Intensive Care Unit-The Smallest and Most Vulnerable Population. (Abstract only.) Pediatric Emergency Care. 29(1):107-13.
The authors describe a full-scale neonatal intensive care unit evacuation exercise and emphasize the importance of constant, clear communication.
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Gray, B.H., and Hebert, K. (2007). Hospitals in Hurricane Katrina: Challenges Facing Custodial Institutions in a Disaster. Journal of Health Care for the Poor and Underserved. 18(2):283-98.
This report is based on interviews with hospital executives, public officials, leaders of trade associations, and others with firsthand experience of the flooding in New Orleans. It addresses what happened in New Orleans-area hospitals during and after Hurricane Katrina and why hospitals had such varied experiences. The authors conclude with lessons based on the Katrina experience.
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Haghpanah, F., Ghobadi, K., and Schafer, B. (2021). Multi-Hazard Hospital Evacuation Planning During Disease Outbreaks Using Agent-Based Modeling. International Journal of Disaster Risk Reduction. 60.
This article discusses planning for hospital evacuation during an ongoing infectious disease outbreak, by describing an evacuation exercise at the Johns Hopkins Hospital during COVID-19. The authors found that more nursing staff can expedite the evacuation process, while an exit door specifically for patients affected by the outbreak can somewhat reduce the evacuation time. The article contains several tables and figures that illustrate evacuation time and effectiveness of evacuation simulations.
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Hariri-Ardebili, M. (2020). Living in a Multi-Risk Chaotic Condition: Pandemic, Natural Hazards and Complex Emergencies. International Journal of Environmental Research and Public Health. 17(16).
The authors studied the effect of natural hazards occurring concurrently with the COVID-19 pandemic, and how healthcare facilities respond to multiple challenges. They found that multiple natural hazards at a time may have cascading effects, and advocate for more risk research on concurrent crises.
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Hicks, J., and Click, R. (2015). A Meta-Analysis of Hospital Evacuations: Overcoming Barriers to Effective Planning. (Abstract only.) Journal of Healthcare and Risk Management. 34(3):26-36.
The authors of this study reviewed literature related to hospital evacuations over the past 30 years. The objectives of this study were: 1) to explain why hospital evacuation planning and preparation is important, and 2) to present the results of a thorough review of the literature. The authors share that the success or failure of hospital evacuations generally fall into one or more of the following eight categories: Predisaster Assessment, Logistics, Communications, Community Relationships, Manual Records and Tracking, Resource Management, Special Patient Populations, and Postevacuation Return.
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Iserson, K. (2013). Vertical Hospital Evacuations: A New Method. (Abstract only.) Southern Medical Journal. 106(1):37-42.
Evacuating non-ambulatory patients is challenging in non-disaster times, let alone during a crisis. This article describes how using available materials (e.g., mattresses and sheets) can help make vertical evacuation easier.
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King, M.A., Dorfman, M.V., Einav, S., et al. (2015). Evacuation of Intensive Care Units during Disaster: Learning From the Hurricane Sandy Experience. (Abstract only.) Disaster Medicine and Public Health Preparedness. 0:1–8.
The authors of this study surveyed nurses, respiratory therapists, and physicians who played direct roles during the Hurricane Sandy intensive care unit (ICU) evacuations to learn about their experience and lessons learned related to preparedness efforts. Results indicated that ICU providers who evacuated critically ill patients during Hurricane Sandy had little prior knowledge of evacuation processes or vertical evacuation experience. The weakest aspects in the patient evacuation process were communication and the availability of practical tools.
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McGinty, M., Burke, T., Barnett, D., et al. (2016). Hospital Evacuation and Shelter-in-Place: Who Is Responsible for Decision-Making? (Abstract only.) Disaster Medicine and Public Health Preparedness. 10(3):320-324.
The authors of this article conducted semi-structured interviews with decision makers to understand reasoning behind making evacuation or shelter-in-place decisions during Hurricane Sandy (2012). They found that perceived authority among hospital executives and government officials was necessary for the decision maker to order evacuation, and there is a risk of inaction when government officials and hospital executives both view themselves as having this authority.
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Ricci, K.A., Griffin, A.R., Heslin, K.C., et al. (2015). Evacuate or Shelter-in-place? The Role of Corporate Memory and Political Environment in Hospital-evacuation Decision Making. (Abstract only.) Prehospital and Disaster Medicine. (3):233-8.
The authors conducted this study to identify factors that most heavily influenced the decisions to evacuate the U.S. Department of Veterans Affairs New York Harbor Healthcare System's Manhattan Campus before Hurricane Irene in 2011 and before Superstorm Sandy in 2012. The most influential factor in the decision to evacuate was New York City's hospital-evacuation mandate. Results indicated that hospital evacuation decisions are confounded by political considerations and are influenced by past disaster experience.
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Rimstad, R., and Holtan, A. (2015). A Cross-Sectional Survey of Patient Needs in Hospital Evacuation. (Abstract only.) Journal of Emergency Management. 13(4):295-301.
The authors conducted a study of a hospital’s inpatient needs in the event of a total evacuation within a few hours. As part of the study, a doctor or nurse on each ward registered patients' physical mobility, any special needs complicating transportation (e.g., intensive care, labor, or isolation), and the lowest acceptable level of care after evacuation. Of the 760 included patients, more than half could walk, and nearly 20% either needed a wheelchair or transport on stretcher. Special needs were registered for 18.2% of patients. Close to 50% of patients needed to be evacuated to another hospital to continue care on an acceptable level. The manual can be replicated by others interested in carrying out similar exercises.
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Sahebi, A., Jahangiri, K., Alibabaei, A., et al. (2021). Factors Influencing Hospital Emergency Evacuation during Fire: A Systematic Literature Review. International Journal of Preventive Medicine. 12:147.
The authors conducted a systematic literature review to review factors leading to hospital (U.S. and abroad) evacuation during a fire. The authors identified themes that affected evacuation including incident/fire characteristics, response measures, patient and staff characteristics, level of hospital preparedness, and building characteristic. They found that hospital preparedness was one of the main factors related to reducing evacuation time.
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Sternberg, E., Lee, G.C., and Huard, D. (2004). Counting Crises: US Hospital Evacuations, 1971-1999. (Abstract only.) Prehospital and Disaster Medicine. 19(2):150-7.
The authors reviewed various types of articles to determine causes for hospital evacuations and found that more than half were due to hazards originating inside of the facility or from "human intruders." They emphasize the need for data gathering and reporting to facilitate the calculation of national data.
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Taaffe, K., Johnson, M., and Steinmann, D. (2006). Improving Hospital Evacuation Planning Using Simulation. (Free registration required.) Department of Industrial Engineering, Clemson University.
The authors of this report address the development of a simulation model and initial analysis to assess the effectiveness of an evacuation plan given different scenarios and resources. This is a promising first step towards developing a resource/ time model that could be refined and broadened by future efforts.
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This case study explores the lessons learned when the North Shore-Long Island Jewish Health System evacuated three hospitals at high risk of flooding from Hurricane Irene in August 2011. The event resulted in the evacuation, transport, and placement of 947 patients without any resulting deaths or serious injuries. This case demonstrates the utility of having a functional evacuation plan in place, such as the one North Shore-Long Island Jewish Health System developed through its own full-scale exercises in the years following Hurricane Katrina in 2005.
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Vugrin, E.D., Verzi, S.J., Finley, P.D., et al. (2015). Modeling Evacuation of a Hospital without Electric Power. (Abstract only.) Prehospital and Disaster Medicine. (3):279-87.
The authors of this report describe a modeling case study of the 2001 evacuation of the Memorial Hermann Hospital in Houston, Texas. They used a model designed to track such cascading events following loss of infrastructure services and to identify the staff, resources, and operational adaptations required to sustain patient care and/or conduct an evacuation.
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Wapling, A., Heggie, C., Murray, V., et al. (2009). Review of Five London Hospital Fires and Their Management: January 2008- February 2009. NHS London.
This report addresses the actions taken, including evacuation of facilities, and lessons learned from five major hospital fires that occurred in London over a 13 month period.
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Zoraster, R.M., Amara, R., and Fruhwirth, K. (2011). Transportation Resource Requirements for Hospital Evacuation. (Abstract only.) American Journal of Disaster Medicine. 6(3):173-86.
The authors of this study conducted a survey on 62 hospitals in Los Angeles County to assess occupancy and patient transportation needs, and to determine the most efficient deployment of limited transportation resources in the event of a hospital evacuation. This survey demonstrated that approximately 20% of hospital inpatients could be discharged home within a few hours; about 40% of hospital inpatients could be transported via vans, buses, or private cars; and the remaining 40% would need ambulance transportation for evacuation. Additionally, the survey provided information about the distribution of emergency department and intensive care unit patients and the resources they would require during a hospital evacuation.
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Exercise Materials


* District 1 [Michigan] Regional Medical Response Coalition. (2010). Situation Manual: Shelter-In-Place/Evacuation Tabletop Exercise: Long Term Care Facility.
This Situation Manual includes exercise materials from Michigan, where exercise participants were given the tools to implement and evaluate the Long Term Care Facility (LTC) tabletop exercise. The purpose of this exercise was to provide a forum for LTCs and other organization to participate in a facilitated discussion regarding their roles and responsibilities during shelter-in-place and evacuation emergencies.
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Georgia Health Care Association Emergency Preparedness Committee. (2014). Tornado Tabletop Exercise Template.
This template provides exercise leaders and participants with the tools to implement and evaluate a tabletop exercise related to a tornado scenario. The purpose of this exercise was to provide facility leaders with a useful exercise to address tornado threats, issues, and concerns. It also allowed participants to address key issues through a series of self-facilitated discussions, including the evacuation of healthcare facilities. These materials can be replicated by others interested in carrying out similar exercises.
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  • Bridget Kanawati Thank you for your comment. We have updated the broken link with a new one.
    5/17/2017 10:36:30 AM
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    5/16/2017 4:56:24 PM
* Health Care Association of New Jersey. (2012). Mid Summer’s NightMARES: Situation Manual.
This Situation Manual provided exercise participants in New Jersey with the tools to implement and evaluate the tabletop exercise related to long-term care facilities. The purpose of this exercise was to provide participants with an opportunity to evaluate their long-term care facility’s current medical surge capabilities in response to a severe weather event. It focused on the implementation and coordination of internal emergency management plans, policies and procedures, critical decision making, communications capabilities and the ability to manage a disaster situation requiring medical surge or evacuation of residents into the facility’s operations.
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* Illinois Emergency Medical Services for Children. (2013). NICU/Nursery Evacuation Tabletop Exercise Toolkit.
This toolkit provides various resources and tools developed specifically for exercises, and offers guidance on planning, conducting, and evaluating tabletop exercises focused on the neonatal intensive care unit and nursery population.
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This ebook (available for free download with iBooks on Mac or iOS device) serves as a training tool for healthcare personnel that closely simulates a hospital evacuation and provides an interactive experience. The ebook objectives include: identify various mechanical devices for hospital/facility evacuation, perform the mattress-sheet slide method of evacuation, understand personal and institutional emergency preparedness, and to help nursing staff more confident to respond to a disaster. This poster presentation provides additional information: https://training.fema.gov/hiedu/17conf/cmcvey - hospital evacuations.pdf.
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U.S. Department of Homeland Security. (n.d.). Ohio Central Region Hospital Evacuation and Shelter-in-Place Tabletop Exercise. (Accessed 7/11/2022.)
These exercise materials from Ohio’s Central Region Hospitals provided participants with the tools to implement and evaluate a tabletop exercise related to an evacuation and shelter-in-place event scenario. The purpose of this exercise was to provide participants with an opportunity to evaluate the hospitals’ current response concepts, plans, and capabilities. Patient tracking, overall movement (internal and externally to receiving facilities) notifications, and communications were also be evaluated.
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Guidelines and Protocols


California Emergency Medical Services Authority, Hospital Incident Command System. (n.d.). Incident Response Guide: Evacuation, Shelter-in-Place, & Hospital Abandonment. (Accessed 7/11/2022.)
This guide addresses response issues associated with evacuation, shelter-in-place, and hospital abandonment. It includes action items for response starting from 0 hours of the incident to greater than 12 hours, and into demobilization and system recovery. Action items are broken down by Section and Branch Unit (of the Hospital Incident Command System).
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* California Hospital Association. (n.d.). Hospital Repopulation after Evacuation: Guidelines and Checklist. (Accessed 7/11/2022.)
The California Hospital Association worked with subject matter experts to identify best practices and regulatory agency requirements that have to be taken into account when repopulating after full or partial evacuation of general acute care hospital inpatient buildings. The guide includes a checklist that can be completed electronically or printed and filled out by hand.
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* Florida Department of Health. (2011). Hospital Emergency Evacuation Toolkit.
This resource serves as a guidance document for the development of hospital-specific emergency evacuation response plans. The overall goal is to ensure that required evacuations are conducted in a planned, orderly, and consistent manner from hospital to hospital while ensuring sound patient care management throughout the evacuation. The toolkit also provides strategies for effective and efficient staff and patient re-entry processes. Planning checklists for advance-warning evacuation are included along with detailed information about lift/ carry techniques and technologies.
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This resource provides criteria for evacuation decision-making in nursing homes and is intended to assist administrators and healthcare professionals determine whether to evacuate or shelter-in-place during disasters. It also includes guidance on the evacuation process.
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* Illinois Emergency Medical Services for Children. (2009). Neonatal Intensive Care Unit (NICU) Evacuation Guidelines.
These neonatal intensive care unit (NICU) evacuation guidelines were developed by professionals throughout Illinois. A multi-disciplinary committee was also convened to collate personal experiences, recommendations, and current literature on NICU evacuations. This guide is intended to assist healthcare providers assess pre-event vulnerabilities and plan for the evacuation of medically fragile Level III NICU patients while addressing core components of incident management, in conjunction with the promotion of patient safety and evacuation procedures based on lessons learned from past disasters and experiences.
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Jagnarine, S., Van Alphen, D., Gibbs, T., et al. (2018). Hospitals Don't Burn!: Hospital Fire Prevention and Evacuation Guide. World Health Organization, and Pan American Health Organization.
This guidance document was developed to address the vulnerability of hospitals to fires. It is intended that all possible steps should be taken to minimize the hazard of fires in hospitals and the need for evacuation. The guide is applicable to existing hospitals that can be retrofitted to improve safety against fires, and proposed new-build facilities. It is formatted into four sections: Prevention, Suppression, Evacuation, and Training Drills.
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* Los Angeles County Emergency Medical Services Agency. (2012). Evacuation and Shelter-in-Place Guidelines for Healthcare Entities.
This guidance document is comprised of three parts. Part I provides general guidance on the differences between evacuation and shelter in place, including the roles and responsibilities of healthcare facilities and the healthcare system. Part II includes an evacuation and shelter in place plan template that healthcare facilities can use to create or update their own plan. Part III includes a set of two tabletop exercises (shelter-in-place and evacuation) that facility emergency planners may use in the planning phase as they develop their plans to identify needs, gaps, or solutions, and/or may use to educate personnel on the components of their existing plan.
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Pandolfo, J. (2014). Comprehensive Planning for Emergency Evacuation of Healthcare Facilities. Patient Safety and Quality Healthcare.
The author provides a to-do list for developing a healthcare evacuation plan and notes that creating a plan will ensure patient safety during an emergency and increase buy-in from the staff and management.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2017). HPP Coalition Surge Test Webinar.
This webinar was designed to familiarize participants with the HPP Coalition Surge Test. Speakers provided an overview of the test, discussed related requirements, and shared implementation experiences from three states: South Dakota, Texas, and Michigan.
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U.S. Department of Homeland Security. (2019). Planning Considerations: Evacuation and Shelter-in-Place.
This document supports state, local, tribal, and territorial partners in planning for community-based evacuation and/or shelter-in-place protective actions. It summarizes characteristics that jurisdictions should consider when planning for evacuation and/or shelter-in-place operations and builds on Comprehensive Preparedness Guide (CPG) 101: Developing and Maintaining Emergency Operations Plans by providing unique considerations for development of evacuation and shelter-in-place plans. In addition, this document contains job aids and checklists that jurisdictions can customize.
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Zane, R., Biddinger, P., Hassol, A., et al. (2010). Hospital Evacuation Decision Guide. Agency for Healthcare Research and Quality.
This guide was created to assist hospitals in evaluating the factors that influence the decision to evacuate a facility, and can serve as a supplement to the hospital’s emergency plan. It includes a Pre-Disaster Hospital Self-Assessment and discussions of both pre- and post-event evacuation decision-making.
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Lessons Learned and Incident Analysis


In this issue of The Exchange, we highlight the stories of healthcare coalitions, emergency managers, and local practitioners involved in healthcare facility evacuation due to two types of disasters: wildfires and hurricane-related flooding. We also share lessons learned by the private sector and federal staff who helped oversee the evacuation, movement, and care of dialysis patients in the hope that these lessons can help emergency planners identify gaps in their own evacuation plans.
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Staff from Kaiser Hospital Santa Rosa (CA) share their personal experiences with the 2017 wildfire and professional experiences evacuating a hospital in the midst of one.
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In 2017, Houston and surrounding areas were inundated by close to 60 inches of rain in just a few days. Hospitals became islands, roads were impassable, and military and public safety helicopters were brought in to evacuate people from their rooftops. Todd Senters (MHA, FACHE, Service Line Administrator and Facility Administrator at Baptist Beaumont Hospital’s Orange Campus) shares how staff in his facility worked to care for existing patients (and those who were dropped off by helicopter) just prior to having to evacuate due to a breach in the City of Beaumont’s water pumps.
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On December 30th, 2021, healthcare workers at Centura Health’s Avista Adventist Hospital were managing a pandemic and planning for a winter storm. The hospital, which includes a large neonatal intensive care unit, was full, with less than 5% capacity. Unbeknownst to the staff working during that holiday weekend, the Marshall Fire was approaching the building, and would cause some of them to lose their homes while forcing the hospital to evacuate in under two hours. ASPR TRACIE met with five subject matter experts to learn more about their experiences, challenges, and lessons learned.
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This article highlights the unique issues associated with the flooding and the subsequent need to evacuate neonates from New Orleans hospitals after Hurricane Katrina.
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Bernard, M. and Mathews, P.R. (2008). Evacuation of a Maternal-Newborn Area during Hurricane Katrina. (Abstract only.) MCN-The American Journal of Maternal Child Nursing. 33(4):213-23.
The authors describe the efforts of the nursing team at Memorial Medical Center in New Orleans in caring for patients and providing for the evacuation of 16 critically ill newborns from the Level 3 regional neonatal intensive care unit and 5 well newborns and their mothers after Hurricane Katrina.
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Desai, S., Gordon, J., and Harris, C. (2019). The Economic Impact of Hurricane Evacuations on a Coastal Georgia Hospital: A Case Study. Frontiers in Public Health. 7:149.
This article discusses the costs of hospital evacuation before a hurricane, including evacuation expenses and lost revenue (which may continue after the storm). Relocating patients back to the hospital and repairing damage to building infrastructure may also be costly. Emergency planning, bolstering infrastructure, and returning to normal operations as quickly as possible can help mitigate these costs.
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Espiritu, M. (2014). Evacuation of a Neonatal ICU During a Disaster: Lessons From Hurricane Sandy. Northwest Healthcare Response Network.
This article highlights lessons learned and overall experiences related to the vertical evacuation of the neonatal intensive care unit (NICU) from NYU Langone Medical Center during Hurricane Sandy.
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The author of this article describes the evacuating/ sheltering experiences of several New York City hospitals during Hurricane Sandy, and how hospital executives and the New York State Health Commissioner made evacuation decisions.
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Fink, S. (2013). Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. (Book available for purchase.) Crown Publishers.
This award winning book is a narrative account of a hospital in crisis and provides many lessons related to incident command, communications, sheltering in place and evacuation of a hospital during Hurricane Katrina. This book is a “must-read” for all hospital emergency management staff and key clinical providers as a reminder of how decisions under stress can become distorted, and the importance of plans and processes during crisis.
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Fuzak, J. K., Elkon, B.D., Hampers, L.C., et al. (2010). Mass Transfer of Pediatric Tertiary Care Hospital Inpatients to a New Location in Under 12 Hours: Lessons Learned and Implications for Disaster Preparedness. (Abstract only.) The Journal of Pediatrics. 157(1):138-143 e2.
The authors retrospectively evaluated the transfer of 111 patients 8.5 miles in 11.6 hours along parallel (vs series) circuits, allowing simultaneous movement of patients from different areas. The transfers were accomplished using 13 critical care teams, five general crews, two vans, and four other vehicles. This experience demonstrates the safety and efficiency of transferring patients in a parallel fashion.
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The author of this article highlights the challenges and lessons learned associated with evacuating neonates from the New Orleans hospital after Hurricane Katrina.
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This article describes the evacuation efforts and continued operations of hospitals and assisted living facilities in Florida during Hurricane Michael in 2018. It includes links to related resources that describe evacuations during Hurricanes Michael and Florence.
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Gotoh, D., Kunii, Y., Terui, T., et al. (2020). Markedly Higher Mortality Among Psychiatric Inpatients Mandatorily Evacuated After the Fukushima Daiichi Nuclear Power Plant Accident. Psychiatry and Clinical Neurosciences. 75(1):29-30.
This study examined mortality among psychiatry inpatients who were evacuated after the Fukushima nuclear power plant accident in 2011. They found that mortality was higher in these patients, perhaps because of older age and comorbidities, the psychological and physical challenges of evacuation, and separation from their families and communities. The results demonstrate that emergency planners should be mindful of the risks of evacuation for vulnerable people after disasters.
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Haggerty, E. (2013). When Bellevue Had to Evacuate Its Criminally Insane. Bedford and Bowery.
The author addresses having to evacuate patients with serious behavioral health issues, and highlights experiences and challenges faced by Bellevue Hospital in the aftermath of Hurricane Sandy.
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The authors of this article describe the experiences and challenges faced by New York hospitals that had to evacuate due to Hurricane Sandy.
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* Jarrett, M., Schwartz, Z., Solazzo, M., and Tangney, E. (2018). Evacuate or Shelter in Place: A View from the Water's Edge. (Abstract only.) Journal of Emergency Management. 16(2): 95-106.
The authors share the experience of a hospital faced with deciding whether to evacuate or shelter in place while in the path of a hurricane (two years in a row). An appendix at the end can be used as a planning tool to help other facilities facing similar challenges.
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Kanter, R.K. (2012). Regional Variation in Critical Care Evacuation Needs for Children after a Mass Casualty Incident. Disaster Medicine and Public Health Preparedness. 6(2):146-9.
The author modeled the ability of five New York state regions to accept 30 children after a mass casualty incident (MCI), and calculated the time to evacuate patients to PICU beds in other regions when surge exceeded capacity. He found that large metropolitan areas could best accommodate patients following a local MCI and serve as a critical resource to other regions if they need surge support. Ground transportation was found to be quickest for evacuations in large metropolitan areas, while helicopters may be best for areas distant from metropolitan areas.
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Lowe, J.L., Hansen, K.F., Sanger, K.K, and Obaid, J.M. (2016). A 3-year Health Care Coalition Experience in Advancing Hospital Evacuation Preparedness. (Abstract only.) Prehospital and Disaster Medicine. 31(6). 658-662.
The authors of this report discuss efforts made by a healthcare coalition (HCC) to advance and test community capacity for a large-scale hospital evacuation. During this 3-year effort, the HCC utilized a variety of platforms such as workshops, seminars, webinars, tabletops, functional exercises, and culminated with a full-scale exercise testing hospital evacuation.
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Lucile Packard Children’s Hospital Standford. (2015). New System Aims to Simplify Patient Transfers in Emergency. Stanford School of Medicine.
This article discusses the Lucile Packard Children’s Hospital Stanford electronic medical records system, which may make the transfer process of patients safer and more efficient in the event of an evacuation due to a major crisis (e.g., earthquake or power outage). Caregivers have access to an automated report that categorizes patients in terms of their specific needs (e.g., what types of intravenous medication they receive, whether they’re on ventilators, or whether they need an intensive care unit bed). This system is part of a Stanford-designed program called TRAIN (Triage by Resource Allocation for Inpatients), which helps determine what vehicles and equipment are necessary for continuous patient care during a crisis event and simplifies communicating patients’ needs to other hospitals or command centers coordinating transfers.
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McGinty, M., Burke, T., Resnick, B., et al. (2017). Decision Processes and Determinants of Hospital Evacuation and Shelter-in-Place During Hurricane Sandy. (Abstract only.) Journal of Public Health Management and Practice. 23(1):29-36.
The authors conducted semi-structured interviews with 42 people responsible for evacuation or shelter in place decisions during Hurricane Sandy. They found that the most important factors in the evacuation decision were patient health, previous experience evacuating, flood risk, and utility outages that could have a negative impact on patient care.
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Nagata, T., Himeno, S., Himeno, A., et al. (2017). Successful Hospital Evacuation After the Kumamoto Earthquakes, Japan, 2016. (Abstract only.) Disaster Medicine and Public Health Preparedness. 11(5):517-521.
This article describes how more than 100 patients were evacuated by multiple agencies following Japan’s two Kumamoto earthquakes, which damaged multiple hospitals in the prefecture. Patients were transported quickly without major adverse events, then returned after hospital repairs were completed. This disaster response can be an international model for coordination and evacuation in the future.
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This intent of the exercise was to evaluate three objectives related to patient placement, patient transportation, and situational awareness during a hospital evacuation exercise utilizing a regional coordination element. This document summarizes the exercise strengths and areas for improvement.
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This article discusses hospital evacuation after the 2011 Fukushima nuclear powerplant accident. Three groups of patients were identified to better understand the evacuation. Because of disruption of infrastructure and staff shortage, some patients died prematurely during the evacuation because they were in poor health, suffered sputum aspirations, lack of medical care like intravenous infusions, or were unable to bear the stresses of evacuation. Evacuation thus should be a part of planning in hospital emergency plans.
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Uppal, A., Evans, L., Chitkara, N., et al. (2013). In Search of the Silver Lining. The Impact of Superstorm Sandy on Bellevue Hospital. ATS Journals. Volume 10, 2.
Staff members of the New York University (NYU) School of Medicine discuss their experience and lessons learned during the evacuation and closure of Bellevue Hospital after Superstorm Sandy and other past storms.
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Plans, Tools, and Templates


Acar, Y., Mehta, N., Rich, M., et al. (2019). Using Standardized Checklists Increase the Completion Rate of Critical Actions in an Evacuation from the Operating Room: A Randomized Controlled Simulation Study. (Abstract only.) Prehospital and Disaster Medicine. 34(4):393-400.
The authors simulated evacuation of a patient under general anesthesia in the operating room to understand the benefit of using a checklist to help providers complete key evacuation steps. Using a checklist was shown to improve completion of critical actions during the simulated evacuation and did not adversely impact evacuation time.
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Agency for Healthcare Quality and Research. (2008). Mass Evacuation Transportation Model.
This computer model can help healthcare planners estimate the time required to evacuate and transport patients and others from healthcare facilities to receiving facilities. The model considers: the numbers of available ambulances, wheelchair vans, and buses; the location of evacuating and receiving facilities; and the surge capacity of receiving facilities.
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* Assisted Living Federation of America. (n.d.). Emergency Preparedness Tool Kit. (Accessed 7/11/2022.)
This toolkit provides information and resources for assisted living facilities leadership, and can help them prepare and plan for events that may cause evacuation or sheltering in place. Appendices also include an employee survey for emergency help, evacuation policies and procedures, an evacuation agreement, an authorization to disclose health information, and an emergency preparedness checklist for senior living communities.
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This plan is designed to assist in activating sheltering, patient relocation, or partial or full evacuation of a healthcare facility. It provides action steps, and includes a decision tree to help guide facilities on whether to shelter, evacuate, or relocate. It also includes various templates and checklists (e.g., incident management staff checklists).
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* California Hospital Association. (n.d.). Hospital Repopulation after Evacuation: Guidelines and Checklist. (Accessed 7/11/2022.)
The California Hospital Association worked with subject matter experts to identify best practices and regulatory agency requirements that have to be taken into account when repopulating after full or partial evacuation of general acute care hospital inpatient buildings. The guide includes a checklist that can be completed electronically or printed and filled out by hand.
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California Hospital Association. (2010). Hospital Evacuation Plan (Checklist).
This resource provides a checklist and decision tree, which can be used to guide hospitals in the development or update of an evacuation plan. It contains detailed information, instructions, and procedures that can be engaged in any emergency situation requiring hospital evacuation (full or partial), as well as sheltering in place.
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California Hospital Association. (2011). Hospital Shelter in Place Planning Checklist.
This resource provides a checklist and decision tree, which can be used to assist hospitals with developing, reviewing, or updating their shelter in place plans.
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* Carbine, D., Cohen, R., Hopper, A., et al. (2014). Neonatal Disaster Preparedness Toolkit. California Association of Neonatologists.
This toolkit identifies major hazards faced by neonatal intensive care units in California and provides suggested mitigation and response planning strategies, including evacuation and sheltering in place. It also provides appendices with sample check lists, job action sheets, and information transfer sheets for specific hazards.
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These two resources can help healthcare facilities develop their plans specific to evacuation or reception of patients in the event of a disaster. While specific to the State of Colorado, the documents can be used as models by other states.
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* Florida Department of Health. (2011). Hospital Emergency Evacuation Toolkit.
This resource serves as a guidance document for the development of hospital-specific emergency evacuation response plans. The overall goal is to ensure that required evacuations are conducted in a planned, orderly, and consistent manner from hospital to hospital while ensuring sound patient care management throughout the evacuation. The toolkit also provides strategies for effective and efficient staff and patient re-entry processes. Planning checklists for advance-warning evacuation are included along with detailed information about lift/ carry techniques and technologies.
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This resource provides criteria for evacuation decision-making in nursing homes and is intended to assist administrators and healthcare professionals determine whether to evacuate or shelter-in-place during disasters. It also includes guidance on the evacuation process.
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This document contains recommended data hospitals can include on a patient transfer form when evacuating a healthcare facility. The form aims to assist with staging an evacuation, providing healthcare during an emergency, triage, and transportation.
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Greater New York Hospital Association. (2017). Evacuation and Shelter in Place Guidance.
This document contains information on roles and responsibilities and an extensive checklist for consideration when planning for and deciding when to evacuate or shelter in place.
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Greater New York Hospital Association. (2017). Patient Evacuation Toolkit.
This toolkit contains resources developed by the "Patient Movement Workgroup" and addresses four priority areas: defining bed types to make bed matching easier; sharing critical information during transport; improving access to medical records after patient transfer; and best practices for credentialing healthcare personnel. It also includes information on Transportation Assistance Levels (stretcher, wheelchair, and ambulatory) and a downloadable job aid worksheet (p. 10).
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Greater New York Hospital Association. (2018). Evacuating Hospital Workbook.
This downloadable Excel worksheet can be used by hospital incident command staff tasked with patient tracking. It can also help with community bed matching and patient transport needs. The Unit Level Form Workbook can be found here: https://www.gnyha.org/tool/unit-level-form-workbook/. The Receiving Hospital Worksheet can be found here: https://www.gnyha.org/tool/receiving-hospital-worksheet/
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This document discusses community and hospital-specific evacuation and sheltering planning during the 2021 storm season. While specific to New York City, it highlights the role of various city facilities (e.g., general and special needs shelters, fire department, department of transportation) in this type of planning.
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Harvard School of Public Health Emergency Preparedness and Response Exercise Program, and Emergency Preparedness Bureau at the Massachusetts Department of Public Health. (2014). MDPH Hospital Evacuation Toolkit.
This toolkit is designed to assist hospitals as they review and update their plans annually for partial or full evacuation. It provides multiple guidance documents (e.g., staffing, assembly point, emergency receiver), and a hospital evacuation plan checklist.
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* Jarrett, M., Schwartz, Z., Solazzo, M., and Tangney, E. (2018). Evacuate or Shelter in Place: A View from the Water's Edge. (Abstract only.) Journal of Emergency Management. 16(2): 95-106.
The authors share the experience of a hospital faced with deciding whether to evacuate or shelter in place while in the path of a hurricane (two years in a row). An appendix at the end can be used as a planning tool to help other facilities facing similar challenges.
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Lane Rose, V. (2019). Evacuate or Shelter in Place? Prepare Ahead for a Critical Decision. Annals of Long-Term Care. 30(1).
This article contains information on types of evacuation a healthcare facility may need to plan for, can help planners understand the risks and benefits of doing so, and highlights steps to take when considering evacuating versus sheltering in place.
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* Los Angeles County Emergency Medical Services Agency. (2012). Evacuation and Shelter-in-Place Guidelines for Healthcare Entities.
This guidance document is comprised of three parts. Part I provides general guidance on the differences between evacuation and shelter in place, including the roles and responsibilities of healthcare facilities and the healthcare system. Part II includes an evacuation and shelter in place plan template that healthcare facilities can use to create or update their own plan. Part III includes a set of two tabletop exercises (shelter-in-place and evacuation) that facility emergency planners may use in the planning phase as they develop their plans to identify needs, gaps, or solutions, and/or may use to educate personnel on the components of their existing plan.
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* Lucile Packard Children’s Hospital. (n.d.). Preplanning Disaster Triage for Pediatric Hospitals: TRAIN TOOLKIT. (Accessed 7/11/2022.)
The Triage by Resource Allocation for IN-patient (TRAIN) matrix is a tool for pediatric hospital disaster “pre-planning” and an in-patient triage system designed to facilitate evacuation in a major crisis. It categorizes pediatric inpatients according to their resource transportation needs. It can be implemented manually or within an electronic medical record.
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This emergency sheltering and evacuation template can be tailored by facility emergency planners. It includes 10 appendices on topics such as relocation, hospital incident command, and supplies.
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* Natarajan, N. (2013). Coastal Storm Planning, the Healthcare Facility Evacuation Center (HEC), and Patient Tracking. New York State Department of Health, Office of Health Emergency Preparedness.
This presentation provides a history of the Healthcare Facility Evacuation Center (HEC) and describes the main objectives of the HEC. It also identifies challenges and describes the events that took place when New York hospitals evacuated during Hurricanes Irene and Sandy.
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New York City Pediatric Disaster Coalition. (2018). Neonatal Intensive Care Unit Surge and Evacuation Plan Template.
This customizable plan template focuses on increasing surge capacity and capabilities for the neonatal intensive care unit during evacuation.
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New York City Pediatric Disaster Coalition. (2018). Neonatal Intensive Care Unit Surge and Evacuation Plan Template.
This customizable plan template focuses on increasing surge capacity and capabilities for the neonatal intensive care unit during evacuation.
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North Dakota Department of Health. (n.d.). Hospital Template Evacuation Plans. (Accessed 7/11/2022.)
This document provides a template for hospitals planning an evacuation procedure for wildfires or other emergencies. It describes steps required when evacuating a healthcare facility, reentering, and receiving patients from another facility which is evacuating patients.
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Reeve, M., Altevogt, B., and Davis, M. (2015). Regional Disaster Response Coordination to Support Health Outcomes: Summary of a Workshop Series. Institute of Medicine.
Chapter 2 of this resource is titled, “Evacuation, Patient Tracking, and Information Sharing in a Regional Response.” This chapter provides key points and challenges identified during a workshop series as it relates to the healthcare facility evacuation and patient tracking process during disaster.
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Southern Maine Regional Resource Center. (2008). Hospital Evacuation Plan Template.
This checklist can be customized by emergency planners responsible for creating or updating healthcare facility evacuation plans.
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* Stanford Medicine Obstetrics and Gynecology. (2015). Stanford OB Disaster Planning Toolkit.
A Stanford Health Care multidisciplinary committee, consisting of obstetricians, obstetrical anesthesiologist, labor and delivery and postpartum nurses, created and tested in a simulated setting, a compilation of tools that can be employed in the event of a hospital disaster requiring evacuation. This toolkit uses the ‘TRAIN’ framework for patient evacuation needs assessment and addresses the evacuation of labor and delivery and antepartum units, and includes shelter in place plans for actively laboring patients.
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Post-Disaster Assessment and Repopulation


American College of Emergency Physicians. (n.d.). Hospital Disaster Preparedness Self-Assessment Tool. (Accessed 7/11/2022.) California Hospital Association.
This detailed checklist assessment can help hospital staff review their emergency operations plan components. This tool includes information on categories that should be considered in a post-disaster assessment (particularly sections 3-7).
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California Emergency Medical Services Authority. (n.d.). Hospital Incident Command System 251- Facility Systems Status Report. (Accessed 7/11/2022.)
This HICS form can be used to determine the status (functional, partially functional, nonfunctional) of a healthcare facility after an emergency event. The function of these systems greatly influences decisions to evacuate following damage to the hospital campus.
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* California Hospital Association. (n.d.). Hospital Repopulation after Evacuation: Guidelines and Checklist. (Accessed 7/11/2022.)
The California Hospital Association worked with subject matter experts to identify best practices and regulatory agency requirements that have to be taken into account when repopulating after full or partial evacuation of general acute care hospital inpatient buildings. The guide includes a checklist that can be completed electronically or printed and filled out by hand.
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This page provides information to assist healthcare facilities with the tasks involved during clean-up and reopening of healthcare facilities after a natural disaster. It includes checklists for mold remediation and structural recovery, water and electrical utilities, ventilation system, structural building materials, medical equipment, certification for occupancy, and post-reoccupation surveillance.
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Florida Healthcare Association. (2016). Post-Storm Recovery Planning Considerations.
This document provides post-storm recovery guidance and checklists for nursing homes/ long term care facilities.
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Greater New York Hospital Association. (2017). Recovery Checklist for Hospitals After A Disaster.
Hospital staff can utilize this facility recovery checklist to check for potential issues in the facility after a disaster.
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South Carolina Department of Health and Environmental Control. (2016). Post-Disaster Hospital Reopening Procedures.
This document provides a step-by-step guide for hospitals to follow prior to reopening. It includes five primary steps with action items under each.
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Wyte-Lake, T., Griffin, A., Dobalian, A., et al. (2018). Supporting Staff Through a Complete Hospital Evacuation and Extended Displacement Period. (Abstract only.) Journal of Healthcare Management. 63(3):195-209.
This article discusses evacuation and subsequent long-term displacement after Hurricane Sandy, especially focusing on staff support and retention. The authors found that monthly forums where staff could ask questions of the organization’s leadership and incorporating cultural considerations between the hosting agency and displaced staff helped ease staff stress.
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Zane, R., Biddinger, P., Gerteis, J., and Hassol, A. (2010). Hospital Assessment and Recovery Guide. U.S. Department of Health and Human Services.
This guide is designed to help hospital staff conduct an initial assessment of a hospital after a closure or evacuation due to an emergency event. The guide is divided into 11 sections, each with its own team and assessment assignment: Administration, Facilities, Security and Fire Safety, Information Technology and Communications, Biomedical Engineering, Medical, Ancillary Services, Materials Management, Building and Grounds Maintenance/ Environmental Services, and Support Services.
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Arkansas Health Care Association. (2017). Evacuation Drill for Long-Term Care Facilities.
This document provides guidance to long-term care facilities that are evaluating their preparedness levels for an evacuation. It contains the materials needed to conduct a simulated evacuation using a tabletop exercise.
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In this issue of The Exchange, we highlight the stories of healthcare coalitions, emergency managers, and local practitioners involved in healthcare facility evacuation due to two types of disasters: wildfires and hurricane-related flooding. We also share lessons learned by the private sector and federal staff who helped oversee the evacuation, movement, and care of dialysis patients in the hope that these lessons can help emergency planners identify gaps in their own evacuation plans.
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* Assisted Living Federation of America. (n.d.). Emergency Preparedness Tool Kit. (Accessed 7/11/2022.)
This toolkit provides information and resources for assisted living facilities leadership, and can help them prepare and plan for events that may cause evacuation or sheltering in place. Appendices also include an employee survey for emergency help, evacuation policies and procedures, an evacuation agreement, an authorization to disclose health information, and an emergency preparedness checklist for senior living communities.
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* District 1 [Michigan] Regional Medical Response Coalition. (2010). Situation Manual: Shelter-In-Place/Evacuation Tabletop Exercise: Long Term Care Facility.
This Situation Manual includes exercise materials from Michigan, where exercise participants were given the tools to implement and evaluate the Long Term Care Facility (LTC) tabletop exercise. The purpose of this exercise was to provide a forum for LTCs and other organization to participate in a facilitated discussion regarding their roles and responsibilities during shelter-in-place and evacuation emergencies.
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* Dosa, D., Hyer, K., Thomas, K., et al. (2012). To Evacuate or Shelter In Place: Implications of Universal Hurricane Evacuation Policies on Nursing Home Residents. Journal of the American Medical Directors Association. 13(2): 190 e1-7.
The objective of this study was to examine the differential morbidity/mortality associated with evacuation versus sheltering in place for nursing home residents exposed to four hurricanes in the Gulf region. The authors discuss their methodology and results of the study. Among residents exposed to hurricanes, evacuation significantly exacerbated subsequent morbidity/mortality.
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This resource provides criteria for evacuation decision-making in nursing homes and is intended to assist administrators and healthcare professionals determine whether to evacuate or shelter-in-place during disasters. It also includes guidance on the evacuation process.
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* Health Care Association of New Jersey. (2012). Mid Summer’s NightMARES: Situation Manual.
This Situation Manual provided exercise participants in New Jersey with the tools to implement and evaluate the tabletop exercise related to long-term care facilities. The purpose of this exercise was to provide participants with an opportunity to evaluate their long-term care facility’s current medical surge capabilities in response to a severe weather event. It focused on the implementation and coordination of internal emergency management plans, policies and procedures, critical decision making, communications capabilities and the ability to manage a disaster situation requiring medical surge or evacuation of residents into the facility’s operations.
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This guidebook is designed to help long-term care facilities evaluate their preparedness for an evacuation. It contains the materials necessary to conduct a simulated evacuation using a tabletop exercise.
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New York State Department of Health. (2011). Nursing Home Evacuation Plan.
This workbook provides considerations for nursing home facilities that are developing or updating their evacuation plans. It is intended to be used in any emergency requiring either a full or partial evacuation of the nursing home.
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Peterson, L., June, J., Sakib, N., et al. (2020). Assisted Living Communities During Hurricane Irma: The Decision to Evacuate or Shelter in Place and Resident Acuity. (Abstract only.) Journal of the American Medical Directors Association. 21(8):1148-1152.
This article examined how assisted living community characteristics impacted the decision to evacuate or shelter in place during 2017’s Hurricane Irma in Florida. The authors found that small assisted living communities and those that provide mental health care were more likely to evacuate, and a higher-care license did not necessarily impact the decision to evacuate.
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Sharma, A. and Mace, S. (2021). Nursing Home Evacuations Due to Disasters in the United States Over 22.5 Years From 1995 To 2017. (Abstract only.) American Journal of Disaster Medicine. 16(2):105-121.
The authors examine nursing home evacuations over more than two decades, analyze the types of disasters which led to evacuations (e.g., internal fires, wildfires, hurricanes, and floods), and list the states with the highest number of evacuations to encourage continued planning.
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The authors found that mortality and hospitalizations increased among nursing home residents who lost power and experienced extreme heat after Hurricane Irma in 2017and suggest that alternate sources of power after a storm could improve outcomes.
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This video was developed to be an educational tool for staff training on emergency preparedness specific to long-term care facilities. The scenario follows staff as they deal with a major storm that causes a week-long power outage. The video covers topics including preparedness, sheltering in place, and evacuation.
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* Carbine, D., Cohen, R., Hopper, A., et al. (2014). Neonatal Disaster Preparedness Toolkit. California Association of Neonatologists.
This toolkit identifies major hazards faced by neonatal intensive care units in California and provides suggested mitigation and response planning strategies, including evacuation and sheltering in place. It also provides appendices with sample check lists, job action sheets, and information transfer sheets for specific hazards.
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* Femino, M., Young, S., and Smith, V. (2013). Hospital-Based Emergency Preparedness: Evacuation of the Neonatal Intensive Care Unit-The Smallest and Most Vulnerable Population. (Abstract only.) Pediatric Emergency Care. 29(1):107-13.
The authors describe a full-scale neonatal intensive care unit evacuation exercise and emphasize the importance of constant, clear communication.
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Graciano, A.L., and Turner, D. (2015). Current Concepts in Pediatric Critical Care. (Book available for purchase.) Society of Critical Care Medicine.
Chapter 16 of this book addresses pediatric preparedness, and specifically includes sections on the evacuation of pediatric intensive care units.
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* Illinois Emergency Medical Services for Children. (2009). Neonatal Intensive Care Unit (NICU) Evacuation Guidelines.
These neonatal intensive care unit (NICU) evacuation guidelines were developed by professionals throughout Illinois. A multi-disciplinary committee was also convened to collate personal experiences, recommendations, and current literature on NICU evacuations. This guide is intended to assist healthcare providers assess pre-event vulnerabilities and plan for the evacuation of medically fragile Level III NICU patients while addressing core components of incident management, in conjunction with the promotion of patient safety and evacuation procedures based on lessons learned from past disasters and experiences.
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* Illinois Emergency Medical Services for Children. (2013). NICU/Nursery Evacuation Tabletop Exercise Toolkit.
This toolkit provides various resources and tools developed specifically for exercises, and offers guidance on planning, conducting, and evaluating tabletop exercises focused on the neonatal intensive care unit and nursery population.
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Imai, K., Suzuki, T., Fukaya, S. et al. (2022). A New Quantitative Triage System for Hospitalized Neonates to Assist with Decisions of Hospital Evacuation Priorities. (Abstract only.) Prehospital and Disaster Medicine. 37(3):343-349.
The authors (located in Japan) developed the Neonatal Extrication Triage system to prioritize hospitalized newborns for evacuation and compared it to an existing system (START-Neo-R). Physicians and nurses independently evaluated each patient over a seven-week period and found that the new system was reproducible and correlated with the existing evaluation tool, making it another important tool to consider when evaluating hospitalized neonate evacuation priority.
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* Lucile Packard Children’s Hospital. (n.d.). Preplanning Disaster Triage for Pediatric Hospitals: TRAIN TOOLKIT. (Accessed 7/11/2022.)
The Triage by Resource Allocation for IN-patient (TRAIN) matrix is a tool for pediatric hospital disaster “pre-planning” and an in-patient triage system designed to facilitate evacuation in a major crisis. It categorizes pediatric inpatients according to their resource transportation needs. It can be implemented manually or within an electronic medical record.
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Ma, A., Cohen, R., and Lee, H. (2020). Learning from Wildfire Disaster Experience in California NICUs. Children. 7(10):155.
The authors conducted interviews with healthcare staff who cared for patients in the neonatal intensive care unit (NICU) when evacuation was necessary due to wildfires or other emergencies. The authors discuss equipment needs, transport by ambulance, teamwork, documentation, and charting required when evacuating babies from the NICU.
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* Stanford Medicine Obstetrics and Gynecology. (2015). Stanford OB Disaster Planning Toolkit.
A Stanford Health Care multidisciplinary committee, consisting of obstetricians, obstetrical anesthesiologist, labor and delivery and postpartum nurses, created and tested in a simulated setting, a compilation of tools that can be employed in the event of a hospital disaster requiring evacuation. This toolkit uses the ‘TRAIN’ framework for patient evacuation needs assessment and addresses the evacuation of labor and delivery and antepartum units, and includes shelter in place plans for actively laboring patients.
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Thomas, A., Gray, M., Burns, B., et al. (2020). EVAC: Evacuation of Vulnerable and Critical Pediatric Patients for Nurses. Cureus. 12(5).
Newborns requiring care in a neonatal intensive care unit (NICU) are vulnerable during disasters, and so can be challenging to manage during an emergency evacuation. The authors simulated evacuation of a critically ill newborn by a nurse after an earthquake, the results of which are discussed here. The article includes the checklist used and tables showing simulation setup, initial patient presentation, scenario progression, and participant evaluations of the exercise.
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Tullius, Z., Helgesen, W., Mulla, Z., et al. (2022). An Evacuation Simulation in Multiple Neonatal Intensive Care Units Across a Single City: Lessons Learned. (Abstract only.) Disaster Medicine and Public Health Preparedness. 3:1-8.
This article describes an exercise conducted in El Paso, Texas, in which six neonatal intensive care units (NICUs) simulated an emergency evacuation involving NICU staff and first responders. Independent evaluators used a standardized tool to measure staff competencies; post-exercise reactions were measured by staff surveys. Overall, the exercise improved NICU staff evacuation skills and familiarized first responders with this patient population. Teamwork, understanding of evacuation equipment, and patient tracking were strengths identified during the exercise.
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Agencies and Organizations


California Hospital Association. Hospital Evacuation.
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Greater New York Hospital Association. Evacuation and Sheltering Issues.
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Massachusetts Department of Public Health. Hospital Evacuation Toolkit.
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Minnesota Department of Health. Health Care Sheltering and Relocation.
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