Healthcare Facility Evacuation/Sheltering
Topic Collection
July 10, 2024
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
On February 7, 2023, a 10-alarm fire at Signature Healthcare Brockton Hospital (Massachusetts) resulted in the total evacuation of the hospital, continued closure, and extensive recovery efforts. In this webinar, hospital representatives shared their experience navigating a complete utilities failure during a fire emergency and discussed their successes and challenges of patient movement, transfers, and discharge; maintaining patient and staff safety; managing cascading events; collaboration with local/state/regional partners; and how lessons learned impact facility plans, protocols, and training.
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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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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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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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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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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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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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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
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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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
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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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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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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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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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 authors describe a full-scale neonatal intensive care unit evacuation exercise and emphasize the importance of constant, clear communication.
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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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
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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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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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
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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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 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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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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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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Building managers and healthcare emergency planners can use the information, decision matrix, and plan considerations in this article to help ensure clean air is circulating in facilities during a wildfire, burn event, or other incident that increases particulate matter.
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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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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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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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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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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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On February 7, 2023, a 10-alarm fire at Signature Healthcare Brockton Hospital (Massachusetts) resulted in the total evacuation of the hospital, continued closure, and extensive recovery efforts. In this webinar, hospital representatives shared their experience navigating a complete utilities failure during a fire emergency and discussed their successes and challenges of patient movement, transfers, and discharge; maintaining patient and staff safety; managing cascading events; collaboration with local/state/regional partners; and how lessons learned impact facility plans, protocols, and training.
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The authors discuss patient evacuation from the U.S. Virgin Islands to San Juan, Puerto Rico or Miami, Florida after Hurricanes Irma and Maria during 2017. The authors discuss variable associated with managing these patients in a shelter for patients with certain medical needs.
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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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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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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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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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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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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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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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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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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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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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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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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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This 1.5-hour video is part of a four-video series in which hospital, EMS, and Mountain View Fire Rescue leaders discuss the hospital evacuation during the Marshall Fire on December 31, 2021. The video includes participants from the responding health care coalition, Boulder County Public Health, and health care facilities which were affected.
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This 1-hour video is part of a four-video series in which stakeholders who supported the emergency response to the December 31, 2021, Marshall Fire discuss regional coordination among public health, disaster management, and the local health care coalition. They discuss emergency sheltering, evacuating residents with access and functional needs, and local coordination structures.
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This 1 hour, 20-minute video is part of a four-video series in which stakeholders from public health and a retirement community discuss evacuation and support for residential care facilities during the Marshall Fire on December 31, 2021. The participants discuss transportation, coordination among partners, and considerations for evacuation during the COVID-19 pandemic.
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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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These slides discuss communication, aeromedical evacuation, and lessons learned after 2017 Hurricanes Irma and Maria. Recommendations include assuming communications will be a challenge, identifying ahead of time which patients will require medications or are pregnant and developing a proactive plan to get care to those patients.
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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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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
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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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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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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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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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 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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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 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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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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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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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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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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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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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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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 customizable plan template focuses on increasing surge capacity and capabilities for the neonatal intensive care unit during evacuation.
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This customizable plan template focuses on increasing surge capacity and capabilities for the neonatal intensive care unit during evacuation.
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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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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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This checklist can be customized by emergency planners responsible for creating or updating healthcare facility evacuation plans.
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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
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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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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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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Hospital staff can utilize this facility recovery checklist to check for potential issues in the facility after a disaster.
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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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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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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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Special Populations: Long-Term Care and Assisted Living-Related Resources
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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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 emergency preparedness checklist is geared towards residents, families, and other interested parties. It includes sections for long-term care ombudsmen, and long-term care residents, their family members, friends, personal caregivers, and guardians. Topics include emergency planning and relocation.
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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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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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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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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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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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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 conducted a retrospective cohort study to understand the impact of power failure on 54,095 nursing home residents after Hurricane Irma in 2017. They found that lack of power after Hurricane Irma was “associated with an increased odds of mortality within 7 days and 30 days.” The increased odds of mortality and hospital utilization illustrate the need to better analyze the specific risks and encourage preparedness and regulation to close the gaps.
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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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Special Populations: Pediatric, NICU, and OB/GYN-Related Resources
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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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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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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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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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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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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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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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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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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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
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