Hospital Evacuation Research Articles

Optimization-based decision support to assist in logistics planning for hospital evacuations

The evacuation of the hospital is a very complex process and evacuation planning is an important part of a hospital's emergency management plan. There are numerous factors that affect the evacuation plan including the nature of threat, availability of resources and staff the characteristics of the evacuee population, and risk to patients and staff. The safety and health of patients is of fundamental importance, but safely moving patients to alternative care facilities while under threat is a very challenging task. This article describes the logistical issues and complexities involved in planning and execution of hospital evacuations. Furthermore, this article provides examples of how optimization-based decision support tools can help evacuation planners to better plan for complex evacuations by providing real-world solutions to various evacuation scenarios.

Facilitating emergency hospital evacuation through uniform discharge criteria

BackgroundThough hospitals' operational continuity is crucial, full institutional evacuation may at times be unavoidable. The study's objective was to establish criteria for discharge of patients during complete emergency evacuation and compare scope of patients suitable for discharge pre/post implementation of criteria. Basic proceduresStandards for patient discharge during an evacuation were developed based on literature and disaster managers. The standards were reviewed in a two-round Delphi process. All hospitals in Israel were requested to identify inpatients' that could be released home during institutional evacuation. Potential discharges were compared in 2013–2014, before and after formulation of discharge criteria. Main findingsConsensus exceeding 80% was obtained for four out of five criteria after two Delphi cycles. Average projected discharge rate before and after formulation of criteria was 34.2% and 42.9%, respectively (p<0.001). Variance in potential dischargeable patients was 31-fold less in 2014 than in 2013 (MST=8,452 versus MST=264,366, respectively; p<0.001). Differences were found between small, medium and large hospitals in mean rate of dischargeable patients: 52.1%, 41.5% and 42.2%, respectively (p=0.001). Principle conclusionsThe study's findings enable to forecast the extent of patients that may be released home during full emergency evacuation of a hospital; thereby facilitating preparedness of contingency plans.

A robust possibilistic programming approach to multiperiod hospital evacuation planning problem under uncertainty

AbstractIn this paper, a biobjective programming model is developed to address the hospital evacuation problem under uncertainty. It aims to concurrently minimize the total evacuation time and the total weighted number of unevacuated patients in each period. The presented model considers two types of patients and three transportation modes. Moreover, the evacuating hospitals are divided into two groups. In the first group, it is not possible to send vehicles to the evacuating hospitals due to the poor road condition or congestion, whereas there is no such limitation in the second group. A robust possibilistic programming approach is adopted to deal with the inherent uncertainty in the input data. To cope with the computational complexity of the problem, two well‐known metaheuristic algorithms are developed to solve the large‐sized problems. Finally, several computational experiments and sensitivity analyses are conducted and the results are analyzed.

Hospital Evacuation and Shelter-in-Place: Who Is Responsible for Decision-Making?

During natural disasters, hospital evacuation may be necessary to ensure patient safety and care. We aimed to examine perceptions of stakeholders involved in these decisions throughout the Mid-Atlantic region of the United States during Hurricane Sandy in October 2012. Semistructured interviews were conducted from March 2014 to February 2015 to characterize stakeholders' perceptions about authority and responsibility for acute care hospital evacuation/shelter-in-place decision-making in Delaware, Maryland, New Jersey, and New York during Hurricane Sandy. Interviews were recorded, transcribed, and thematically analyzed using a framework approach. We interviewed 42 individuals from 32 organizations. Hospital executives from all states reported having authority and responsibility for evacuation/shelter-in-place decision-making. In New York and Maryland, government officials stated that they could order hospital evacuation, whereas officials in Delaware and New Jersey said the government lacked enforcement capacity and therefore could not mandate evacuation. Among government officials, perceived authority for hospital evacuation/shelter-in-place decision-making was viewed as a prerequisite to ordering evacuation. When both hospital executives and government officials perceive themselves to possess decision-making authority, there is the potential for inaction. Future work should examine whether a single entity bearing ultimate responsibility or regional emergency response coalitions would improve decision-making. (Disaster Med Public Health Preparedness. 2016;10:320-324).

Decision Processes and Determinants of Hospital Evacuation and Shelter-in-Place During Hurricane Sandy.

Evacuation and shelter-in-place decision making for hospitals is complex, and existing literature contains little information about how these decisions are made in practice. To describe decision-making processes and identify determinants of acute care hospital evacuation and shelter-in-place during Hurricane Sandy. Semistructured interviews were conducted from March 2014 to February 2015 with key informants who had authority and responsibility for evacuation and shelter-in-place decisions for hospitals during Hurricane Sandy in 2012. Interviews were recorded, transcribed, and thematically analyzed. Interviewees included hospital executives and state and local public health, emergency management, and emergency medical service officials from Delaware, Maryland, New Jersey, and New York. Interviewees identified decision processes and determinants of acute care hospital evacuation and shelter-in-place during Hurricane Sandy. We interviewed 42 individuals from 32 organizations. Decisions makers reported relying on their instincts rather than employing guides or tools to make evacuation and shelter-in-place decisions during Hurricane Sandy. Risk to patient health from evacuation, prior experience, cost, and ability to maintain continuity of operations were the most influential factors in decision making. Flooding and utility outages, which were predicted to or actually impacted continuity of operations, were the primary determinants of evacuation. Evacuation and shelter-in-place decision making for hospitals can be improved by ensuring hospital emergency plans address flooding and include explicit thresholds that, if exceeded, would trigger evacuation. Comparative risk assessments that inform decision making would be enhanced by improved collection, analysis, and communication of data on morbidity and mortality associated with evacuation versus sheltering-in-place of hospitals. In addition, administrators and public officials can improve their preparedness to make evacuation and shelter-in-place decisions by practicing the use of decision-making tools during training and exercises.

Legal Preparedness for Hurricane Sandy: Authority to Order Hospital Evacuation or Shelter-in-Place in the Mid-Atlantic Region.

Hospitals were once thought to be places of refuge during catastrophic hurricanes, but recent disasters such as Hurricanes Katrina and Sandy have demonstrated that some hospitals are unable to ensure the safety of patients and staff and the continuity of medical care at key times. The government has a duty to safeguard public health and a responsibility to ensure that appropriate protective action is taken when disasters threaten or impair the ability of hospitals to sustain essential services. The law can enable the government to fulfill this duty by providing necessary authority to order preventive or reactive responses--such as ordering evacuation of or sheltering-in-place in hospitals--when safety is imperiled. We systematically identified and analyzed state emergency preparedness laws that could have affected evacuation of and sheltering-in-place in hospitals in order to characterize the public health legal preparedness of 4 states (Delaware, Maryland, New Jersey, and New York) in the mid-Atlantic region during Hurricane Sandy in 2012. At that time, none of these 4 states had enacted statutes or regulations explicitly granting the government the authority to order hospitals to shelter-in-place. Whereas all 4 states had enacted laws explicitly enabling the government to order evacuation, the nature of this authority and the individuals empowered to execute it varied. We present empirical analyses intended to enhance public health legal preparedness and ensure these states and others are better able to respond to future natural disasters, which are predicted to be more severe and frequent as a result of climate change, as well as other hazards. States can further improve their readiness for catastrophic disasters by ensuring explicit statutory authority to order evacuation and to order sheltering-in-place, particularly of hospitals, where it does not currently exist.

Hospital evacuation: Exercise versus reality

IntroductionThe Dutch Major Incident Hospital (MIH) is a standby, highly prepared, 200-bed hospital strictly reserved to provide immediate, large-scale, and emergency care for victims of disasters and major incidents. It has long-standing experience training for various major incident scenarios, including functioning as a back-up facility for the Netherlands. In 1995, the MIH had experience with overtaking an evacuated hospital when that hospital was threatened by flooding. In November 2014, an exercise was performed to transfer an evacuating hospital to the MIH. The scenario again became reality when a neighbouring hospital had to evacuate in September 2015. This article evaluates the events and compares the exercise to the real events in order to further optimise future training. MethodsAll three events were analysed using the Protocol for Reports from Major Accidents and Disasters, a standardised protocol to evaluate medical responses to a major incident. ResultsDuring the 2014 exercise, 72 patients were received, compared with 143 and 70, respectively, in the real events in 1995 and 2015. Personnel from the evacuating hospitals accompanied the patients and continued working in the MIH. The patient surge differed on all three occasions. The information technology (IT) systems proved to be more prone to fail during the real event, and legal implications to have staff from another hospital work in the MIH had to be put in protocol during the deployment. The acute phase was comparable in all three events, and performance was good. However, the exercise did not last long enough to analyse the implications on multiday care, as experienced during a multiday deployment. ConclusionLarge-scale major incident exercises are a great benchmark for the medical response in the acute phase of relief. The MIH was shown to be highly prepared to admit an entire evacuating hospital or large groups of patients in such a scenario. Experiences from the past, combined with regular training that closely resembles reality, guarantee the level of preparedness. Key differences between a true deployment and an exercise are the inability to train multiple days, and in our experience, a successful operation of IT systems in test environments does not guarantee their successful use during live events.

Legal Considerations for Health Care Practitioners After Superstorm Sandy.

During disaster response and recovery, legal issues often arise related to the provision of health care services to affected residents. Superstorm Sandy led to the evacuation of many hospitals and other health care facilities and compromised the ability of health care practitioners to provide necessary primary care. This article highlights the challenges and legal concerns faced by health care practitioners in the aftermath of Sandy, which included limitations in scope of practice, difficulties with credentialing, lack of portability of practitioner licenses, and concerns regarding volunteer immunity and liability. Governmental and nongovernmental entities employed various strategies to address these concerns; however, legal barriers remained that posed challenges throughout the Superstorm Sandy response and recovery period. We suggest future approaches to address these legal considerations, including policies and legislation, additional waivers of law, and planning and coordination among multiple levels of governmental and nongovernmental organizations. (Disaster Med Public Health Preparedness. 2016;10:518-524).

Modeling and optimizing the evacuation of hospitals based on the MRCPSP with resource transfers

In this paper, we consider the problem of hospital evacuation and model it as a multi-mode resource-constrained project scheduling problem (MRCPSP) with additional resource transfers and blockings. Based on this model two heuristic decomposition approaches are proposed. The first uses a tabu search algorithm for the mode assignment problem, the scheduling subproblem is solved by adapted serial and parallel schedule generation schemes using priority rules. The second is based on a decomposition into an evacuation and a routing subproblem where solutions are represented by resource flows. Computational experiments were performed for both approaches using randomly generated instances based on real-world scenarios.

Hospital evacuation in disasters: uncovering the systemic leverage using system dynamics

Our aim is to understand systemic processes that apply to hospital evacuation and patient relocation during and after a disaster. We use system dynamics to simulate hospital evacuation in such an event. System dynamics is a well-established simulation method for analysing complex social systems that include feedback. We found that the key to efficient hospital evacuation lies less in management of patient transportation and more in the ability of the receiving hospital to manage the influx of patients. The decision makers at the hospital receiving patients are most subject to feedback effects and therefore hold the most leverage in determining the rate of the evacuation. On the basis of simulation results, we develop recommendations for hospital evacuation and patient relocation. Planners, policy makers and practitioners can use the recommendations to facilitate efficient hospital evacuations.

Case study of medical evacuation before and after the Fukushima Daiichi nuclear power plant accident in the great east Japan earthquake.

IntroductionIn Japan, participants in the disaster-specific medical transportation system have received ongoing training since 2002, incorporating lessons learned from the Great Hanshin Earthquake. The Great East Japan Earthquake occurred on March 11, 2011, and the very first disaster-specific medical transport was performed. This article reviews in detail the central government’s control and coordination of the disaster medical transportation process following the Great East Japan Earthquake and the Fukushima Daiichi Nuclear Power Plant Accident.Case descriptionIn total, 124 patients were air transported under the coordination of the C5 team in the emergency response headquarter of the Japanese Government. C5 includes experts from the Cabinet Office, Cabinet Secretariat, Fire Defense Agency, Ministry of Health, Labour and Welfare, and Ministry of Defense. In the 20–30 km evacuation zone around the Fukushima Daiichi nuclear power plant, 509 bedridden patients were successfully evacuated without any fatalities during transportation.Discussion and evaluationMany lessons have been learned in disaster-specific medical transportation. The national government, local government, police, and fire agencies have made significant progress in their mutual communication and collaboration.ResultsFortunately, hospital evacuation from the 20–30 km area was successfully performed with the aid of local emergency physicians and Disaster Medical Assistance Teams (DMATs) who have vast experience in patient transport in the course of day-to-day activities. The emergency procedures that are required during crises are an extension of basic daily procedures that are performed by emergency medical staff and first responders, such as fire fighters, emergency medical technicians, or police officers. Medical facilities including nursing homes should have a plan for long-distance (over 100 km) evacuation, and the plan should be routinely reevaluated with full-scale exercises. In addition, hospital evacuation in disaster settings should be supervised by emergency physicians and be handled by disaster specialists who are accustomed to patient transportation on a daily basis.

A cross-sectional survey of patient needs in hospital evacuation.

To aid development of contingency plans, a cross-sectional survey of inpatient needs in the event of a total hospital evacuation within a few hours was undertaken. The hospital is a part of a tertiary care facility with a mixed surgical and medical population and a relatively large load of emergency medicine. A doctor or nurse on each ward registered patients' physical mobility, special needs complicating transportation (intensive care, labor, isolation, etc), and the lowest acceptable level of care after evacuation. Of the 760 included patients, 57.8 percent could walk, 20.0 percent needed wheelchair, and 22.2 percent needed transport on stretcher. Special needs were registered for 18.2 percent of patients. Only 49.7 percent of patients needed to be evacuated to another hospital to continue care on an acceptable level, while 37.6 percent could be discharged to their own home, and 12.6 percent could be evacuated to a nursing home. Patients in psychiatric wards and high dependency units had distinctly different needs than patients in ordinary somatic wards. The differences between patients in surgical and nonsurgical wards were minor. Patient discharge seems to be a considerable capacity buffer in a hospital crisis situation.

Evacuation of Intensive Care Units During Disaster: Learning From the Hurricane Sandy Experience.

Data on best practices for evacuating an intensive care unit (ICU) during a disaster are limited. The impact of Hurricane Sandy on New York City area hospitals provided a unique opportunity to learn from the experience of ICU providers about their preparedness, perspective, roles, and activities. We conducted a cross-sectional survey of nurses, respiratory therapists, and physicians who played direct roles during the Hurricane Sandy ICU evacuations. Sixty-eight health care professionals from 4 evacuating hospitals completed surveys (35% ICU nurses, 21% respiratory therapists, 25% physicians-in-training, and 13% attending physicians). Only 21% had participated in an ICU evacuation drill in the past 2 years and 28% had prior training or real-life experience. Processes were inconsistent for patient prioritization, tracking, transport medications, and transport care. Respondents identified communication (43%) as the key barrier to effective evacuation. The equipment considered most helpful included flashlights (24%), transport sleds (21%), and oxygen tanks and respiratory therapy supplies (19%). An evacuation wish list included walkie-talkies/phones (26%), lighting/electricity (18%), flashlights (10%), and portable ventilators and suction (16%). ICU providers who evacuated critically ill patients during Hurricane Sandy had little prior knowledge of evacuation processes or vertical evacuation experience. The weakest links in the patient evacuation process were communication and the availability of practical tools. Incorporating ICU providers into hospital evacuation planning and training, developing standard evacuation communication processes and tools, and collecting a uniform dataset among all evacuating hospitals could better inform critical care evacuation in the future.

A cross-sectional survey of patient needs in hospital evacuation.

To aid development of contingency plans, a cross-sectional survey of inpatient needs in the event of a total hospital evacuation within a few hours was undertaken. The hospital is a part of a tertiary care facility with a mixed surgical and medical population and a relatively large load of emergency medicine. A doctor or nurse on each ward registered patients' physical mobility, special needs complicating transportation (intensive care, labor, isolation, etc), and the lowest acceptable level of care after evacuation. Of the 760 included patients, 57.8 percent could walk, 20.0 percent needed wheelchair, and 22.2 percent needed transport on stretcher. Special needs were registered for 18.2 percent of patients. Only 49.7 percent of patients needed to be evacuated to another hospital to continue care on an acceptable level, while 37.6 percent could be discharged to their own home, and 12.6 percent could be evacuated to a nursing home. Patients in psychiatric wards and high dependency units had distinctly different needs than patients in ordinary somatic wards. The differences between patients in surgical and nonsurgical wards were minor. Patient discharge seems to be a considerable capacity buffer in a hospital crisis situation.

Modeling and simulation of a hospital evacuation before a forecasted flood

As high level emergencies can have serious consequences on hospital activities, an emergency management plan to face a crisis situation must be specified and assessed. Even though more and more research is devoted to this area, most studies are based on academic assumptions and the proposed improvement methods are difficult to apply in the real world. This paper deals with a hospital evacuation plan facing a flood based on a real life scenario. We modeled the evacuation process and identified its different activities. We then used SIMIO–a commercial simulation software–to translate our conceptual model into a dynamic model. Numerical experiments were conducted to determine the best way to assign the resources. We also propose two organizational improvements to the current, as-is, evacuation process. By simulating these changes, we were able to show that, if implemented together, they should be able to reduce the evacuation time by 1 h and 18 min, an improvement of 23.8% with respect to the current average evacuation time.

A meta-analysis of hospital evacuations: overcoming barriers to effective planning.

A hospital evacuation is a significant disaster scenario facing today's Hospital Emergency Coordinators (HECs) and Risk Managers. In this work we explore the numerous barriers that prevent HECs from being able to effectively plan for and execute hospital evacuations based on a review of the pertinent literature of the last 30 years. We discuss the finding that the reasons for the success or failure generally fall into 1 or more of 8 broad categories: Predisaster Assessment, Logistics, Communications, Community Relationships, Manual Records and Tracking, Resource Management, Special Patient Populations, and Postevacuation Return.

Experience from the Great East Japan Earthquake response as the basis for revising the Japanese Disaster Medical Assistance Team (DMAT) training program.

The objective of this study was to draft a new Japanese Disaster Medical Assistance Team (DMAT) training program based on the responses to the Great East Japan Earthquake. Working group members of the Japan DMAT Investigative Commission, Ministry of Health, Labour and Welfare, reviewed reports and academic papers on DMAT activities after the disaster and identified items in the current Japanese DMAT training program that should be changed. A new program was proposed that incorporates these changes. New topics that were identified to be added to the DMAT training program were hospital evacuation, preparations to receive DMATs at damaged hospitals, coordination when DMAT activities are prolonged, and safety management and communication when on board small helicopters. The use of wide-area transport was reviewed and changes were made to cover selection of various transport means including helicopter ambulances. Content related to confined space medicine was removed. The time spent on emergency medical information system (EMIS) practical training was increased. Redundant or similar content was combined and reorganized, and a revised DMAT training program that did not increase the overall training time was designed. The revised DMAT training program will provide practical training better suited to the present circumstances in Japan.

Prerequisites of preparedness against earthquake in hospital system: a survey from Iran.

Background and Objective:Considering the history of frequent, and severe, earthquakes in Iran and the importance of health care service delivery by hospitals in these cases, having a plan to deal with disasters should be considered a priority. The aim of this study was the observance of preparedness prerequisites against earthquake in hospitals affiliated with Shahid Beheshti University of Medical Sciences (SBUMS) and its relationship with demographic and organizational characteristics.Methods:This was a cross- sectional study that was conducted in 15 hospitals affiliated with SBUMS, Iran in 2012. Data were collected using observation of documents and questionnaire consists of 138 questions in 8 dimensions. The content validity and reliability were confirmed. Data analysis was performed with descriptive statistic, t-test and ANOVA.Results:Results showed that 86.7% of hospitals were in good preparedness level, with the average 85.9 ± 15.5. The maximum and minimum level of preparedness was related to mitigation of construction hazards (56.6 ± 35.6) and support of vital services (97.2 ± 6.0) dimensions, respectively. According to the results, there was a significant statistical difference between mean preparedness and safety of equipment and hazardous materials, hospital evacuation and field treatment, hospital environmental health proceedings, hospital curriculum programs and support of services dimensions with management experience (P<0.05).Conclusion:Although results corroborate that preparedness prerequisites against earthquake are in good level but attention to the weaknesses mitigation of construction hazards dimension and strengthening these prerequisites, which have obvious impacts on the structural vulnerability of hospitals and adjacent buildings in earthquakes, have been proposed.

Hospital Evacuation; Learning from the Past? Flooding of Bangkok 2011

Aims: To evaluate hospital evacuation in light of recent hospital evacuations in Bangkok and surrounding areas. This information was compared with results reported in the literature. Study Design: Retrospective and qualitative. Place and Duration of Study: Bangkok, Thailand, December 1 to December 11, 2011. Methodology: Four facilities were included in this study, three hospitals and one “prehospital” facility, each of which had either experienced evacuation or had been receiving facilities during disaster response operations. Data were obtained using questionnaires and interviews to characterize facility backgrounds and capacities. Responses were obtained from one representative of each of the four Thai facilities. The questionnaire was designed for this study following recommendations by an earlier Swedish study that employed “risk and vulnerability analysis” (RVA), and was further Research Article British Journal of Medicine & Medical Research, 4(1): 395-415, 2014 396 adapted according to results of a literature review. Results: Overall, consistent results in the literature, as well as in the recent Thai disaster experience, about hospital evacuation indicate shortcomings in planning (including training), command and control, communication, support, resources and transportation. Patient safety, transfer of medical data, care and treatment of patients during transportations showed positive outcomes in recent Thai evacuations. Conclusion: Despite numerous previous findings and recommendations found in the literature, the need exists for continuous improvement in evacuating a hospital, especially in improving planning (coordinated emergency plans and synchronized exercises), leadership, communications and collaboration and implementation of best medical facility response to disasters.

Absorbing Citywide Patient Surge During Hurricane Sandy: A Case Study in Accommodating Multiple Hospital Evacuations

Hospital evacuations have myriad effects on all elements of the health care system. We seek to (1) examine the effect of patient surge on hospitals that received patients from evacuating hospitals in New York City during Hurricane Sandy; (2) describe operational challenges those hospitals faced pre- and poststorm; and (3) examine the coordination efforts to distribute patients to receiving hospitals. We used a qualitative, interview-based method to identify medical surge strategies used at hospitals receiving patients from evacuated health care facilities during and after Hurricane Sandy. We identified 4 hospital systems that received the majority of evacuated patients and those departments most involved in managing patient surge. We invited key staff at those hospitals to participate in on-site group interviews. We interviewed 71 key individuals. Although all hospitals had emergency preparedness plans in place before Hurricane Sandy, we identified gaps. Insights gleaned included improvement opportunities in these 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. Our qualitative, event-based research identified key opportunities to improve disaster preparedness. The specific opportunities and this structured postevent approach can serve to guide future disaster planning and analyses.