Assessment on Deciding to Evacuate or Shelter in Place for Hospitals During Hurricanes

ABSTRACT

Hurricanes Katrina and Sandy produced widespread damage and massive disruption to health and medical providers. The widespread damage caused some hospitals to evacuate and others to shelter-in-place. It is a difficult decision that state, cities, and hospital leadership have to address during uncertain times. Conducting an evacuation of a hospital is considered to be the last resort (Childers, Mayorga, & Taaffee, 2014).  Evacuations can expose patients to dangerous external conditions that result in unintended consequences that exacerbate the patients’ health (Bjarnadottir, Li, & Stewart, 2011).  The process requires assessing the situation and predictions, understanding capabilities, and identifying vulnerabilities.

This study examines the decision through a comparative analysis of four hospitals, two from Hurricane Katrina, and two from Hurricane Sandy, that made opposing decisions when faced with the same threat.  The study identifies that internal capability and vulnerability assessments to be the driving force behind evacuation decisions.  The hospitals that chose to evacuate prior to the hurricanes making landfall had accurately assessed their capabilities and understood the limitations to their capabilities to care for patients.

INTRODUCTION

Introduction to the Problem

Hospitals provide essential care to millions of Americans every day.  The care provided by hospitals and clinics is essential to the wellbeing of these patients.  The complex health system infrastructure is dependent on continued functionality when emergencies occur.  Hospitals must remain capable of providing services regardless of the emerging threats or disaster that they may face at any giving time.

Hurricanes are complex storms that pose many challenges for communities near the coastal United States.  There are many characteristics of hurricanes that contribute to the overall impact it inflects on communities.  Wind speed, latent heat, combative weather fronts, trade winds, and interaction with land can help shift the severity and path of hurricanes.  The continued development characteristics of hurricane are important because it could dictate the actions that one will take regarding safety.  The increase in intensity may draw leaders to error on the side of taking a more protective stance, or alternatively discount the potential to cause damage when the severity of the storm decreases.

Physical damage to hospitals or disruption of services can lead to detrimental consequences.  It is essential to understand the best course of action for hospitals to take when facing an uncontainable hurricane.  Hospitals have only two main options when facing a hurricane; they can either ride out the storm and shelter in place, or evacuate the hospital to an alternate care facilities located in a safer area.

Statement of the Problem

Hospitals provide critical care to people and are expected to remain fully functional at all times, including during events that disrupt service.  Over seven percent of the United States population has stayed at least one night in a hospital during 2014 (Center for Disease Control, 2016).  This results in over 22 million people that receive vital medical services that required individuals to remain in the care of hospitals overnight.

Hospitals are located where there are sufficient populations that justify the services they provide.  In 2010, 123.3 million people, or 39 percent of the nation’s population lived in counties directly on the shoreline (National Oceanic and Atmospheric Administration, March 2013). Coastal communities are prone to experiencing the devastating impacts from hurricanes.  The annual damage caused by hurricanes in recent years is near $6 billion with the 2004-2005 Atlantic hurricane seasons causing a staggering $150 billion in damages (Bjarnadottir, Li, & Stewart, 2011).

Hospitals face many challenges when ensuring their services remain operational during disruptions.  Hurricanes pose many threats that could influence their ability to remain functioning.  Hospital leadership, based on current models, conducts an assessment based on predictions, to either remain in their facility (shelter-in-place) or evacuate to alternative facilities that reside in a safer location (evacuation).  The decision to evacuate or shelter-in-place in advance of a hurricane is complex and time sensitive based on potential uncertainty (Ricci, Griffin, Heslin, Kranke, & Dobalian, 2015).  If a hospital waits to evacuate, they could endanger patients, staff, and ability to provide continuation of services.  If a hospital chooses to ‘ride out’ the hurricane, they could endanger patients if not adequately prepared to handle potential impacts.  It is vital to assess historic actions taken during hurricanes by hospitals and lessons learned for decisions.

Background of the Study

After devastating disasters, there is often criticism of decisions that were made by those in leadership positions.  It is easy to provide opinions and conduct an after-action that examines actions that were taken during an uncertain time.  The decision to evacuate a hospital has many variables that leadership must consider.  Ultimately, the decision to evacuate hospital should be made to ensure the continued care of patients, safety of staff, and minimizing potential impacts. The decision should not be based the convenience or cost of executing an action.  It is important to look at historic examples and understand the reasoning behind the decisions with the most current information.

Hurricane Katrina and Hurricane Sandy caused widespread damage across Louisiana, Mississippi, New York, New Jersey and Connecticut. Millions were impacted by the two hurricanes ranging from flooding, wind damage, power loss, gas shortages, and disruption to routine essential services (New York City, 2013, Andress, 2009).  These disruptions included impacts on hospitals that faced an increase demand for medical attention by those injured during the hurricanes.  Hospital services must remain operational, either in their original facility, or at an alternate location that is in a safer location.

Purpose Statement

The purpose of this research is to gain insight into opposing decisions made by hospitals when faced with the same threat.  Why did one hospital evacuate and another decide to shelter-in-place when facing the same hurricane?  There are many possible answers to this question and it is important to understand the reasons.  A careful analysis of recent examples provides an opportunity to gain the insight into the possible variables that exist when hospital leadership make their decisions.  Was it a lack of planning?  Lack of logistical support?  Did the underestimate the damage from the hurricane?  It is important to look beyond one example and to gain insight from multiple events from two distinct hurricanes.

LITERATURE REVIEW

Preparedness Activities

Hospitals prepare for many different situations that may affect their capabilities to operate and care for their patients.  The scope and expectations for preparedness activities can come from multiple levels.  Hospital leadership may direct preparedness efforts at an organization level based on leadership concerns, local environment, or previous events.  A comprehensive threat assessment of the hospital service area can motivate these decisions.

Research on hospital preparedness covers a wide span of scenarios and topics.  Little research has focused specifically on preparedness of hospital evacuation.  A study conducted by Jafari, Golmohammadi, and Seyed (2008) focuses on resource management allocation in a fictitious hospital.  The simulation includes a hospital with eight stories that have specific capabilities and levels of care spread across floors.  Patients are categorized as either ambulatory or nonambulatory.  Five processes are applied to a scenario to identify what resource dispatch process results in the most expedient evacuation.  The study concluded that resource allocation using a ‘float pool’ of human services, medical and non-medical, to direct to specific areas reduces the time needed to safely evacuate staff, patients, and guest (Jafari, Golmohammadi, & Seyed, 2008).  The conclusion of the study verifies the importance of resource allocation strategies, but does not address the primary concern related to the effectiveness of evacuation of a hospital compared to sheltering in place.

There are many resources available for hospital preparedness activities related to emergencies.  The United States Department of Health and Human Services (DHHS) has several programs that assists hospitals prepare for emergencies.  The Assistant Secretary for Preparedness and Response (ASPR) manages the Hospital Preparedness Program (HPP).  This program enables health care systems to save lives during emergencies that exceed normal daily capacity (U.S. Department of Health and Human Services, n.d.).  Sixty-two awardees – health department within states, localities, and territories – use health care coalitions (HCCs) as a means of providing support (U.S. Department of Health and Human Services, n.d.).

It is important to understand the definition of what an HCC is and what the benefits are health and medical providers.  DHHS defines a HCC as a group of individual health care and response organizations, emergency management organizations, public health agencies, in a defined geographic location (U.S. Department of Health and Human Services, 2016).  HCCs function as a collaborative group that supports various medical and public health activities in the context of incident command system (ICS) responsibilities.  HCCs are a critical player in developing health care delivery system preparedness and response capabilities.  In 2016, there was a total of 486 HCCs, encompassing 26,271 members, playing an active part in healthcare preparedness activities through the HPP (U.S. Department of Health and Human Services, n.d.).

The history of HPP has shifted its focus and priorities over the history of the program. From 2002 to 2011, the program focused on purchasing equipment.  The equipment purchased during this time allowed for medical personal protection equipment, medical cache supplies, emergency pharmaceutical supplies, generators, durable medical equipment, and communication enhancements.  This phase focused on building capacity and increasing the means to conduct emergency operations related to logistics.

From 2012 to 2016, the program aimed at going past the equipment and focused on promoting health care capabilities through forming HCCs.  The development of HCCs allows member agencies to leverage resources in a collaborative effort by forming geographic partnerships with member agencies involved in health and medical planning.

From 2017 and beyond, the program will focus on operationalizing the HCC for effective response by using their designated geographic area, increased capabilities, and supplies.  This transition compliments the previous two focus areas.  Having the right tools and equipment paired with the right structure and organization allows for the concept of operationalizing during emergencies more manageable.

Federal support is not the only option to coordinate hospital preparedness.  State hospital preparedness activities are directed and coordinated by a state agency.  These agencies work with federal partners and local communities.  The designated agencies have the ability to create and implement their own health and medical preparedness programs that address anything outside the focus of federal programs.  Efforts led by state agencies can fill gaps that are identified by local hazard assessments and better serve hospitals and HCCs within various geographic areas.

States have the ability to require various preparedness requirements through the licensing and oversight.  Requirements are implemented through legislation and/or policy.  The focus of law and policy by states primarily focus on standards of care and operational capability. Emergency preparedness activities and capabilities standards are enforced through hospitals seeking accreditation through various organizations.

Training

Training, related to emergency management, falls under preparedness.  Training helps expand skillsets and maintain capabilities.  Hurricanes can cause widespread damage and create challenging scenarios for medical professionals.  It is important for hospitals to conduct training to expose members to possible situations, testing their capabilities and going beyond routine environments.  Training can occur in many forms to include online course, instructor led, or attending a seminar or conference.  Doctors, nurses, and many medical professions are required to take continuing education to maintain their certifications (Baioni, et al., July 2013).  The benefit expands beyond the individual and crosses into the organization.

Little research has been conducted on the benefits of training related to hospital evacuation.  A study conducted by Williams, Nocera, and Casteel looked at the effectiveness of training pertaining to disasters (Williams, Nocera, & Casteel, September 2008).  The study covers multiple scenarios for hospital emergencies including mass casualty and bioterrorism.  The primary goal of the study was to assess the effectiveness of deliver means for emergency training, online and lecture.  The conclusion of study found that available evidence was insufficient to determine if emergency training for health care providers was effective in improving knowledge and skills in emergency response (Williams, Nocera, & Casteel, September 2008).  The study cited a large span of topics related to emergency preparedness as being an obstacle to confirm the benefit of training.  However, hospital evacuation was not included and assessed during the study.

In the absence of research related to training on evacuations within hospitals, many beneficial training opportunities are available to hospitals to support emergency management efforts.  The online trainings and webinars are an excellent tool to be used by hospitals to create an internal training program aimed towards identified threats and hazards.

The Disaster Information Management Research Center, provided by DHHS and the National Institute of Health, has collected 11,970 trainings, webinars, and resources for health and medical professionals.  This searchable depository helps pinpoint topics that are relevant to a hospital regarding specifics scenarios that are prudent to the preparedness phase.  A search of “hospital evacuation” resulted in thirty-two resources, trainings, and webinars that could be used to support a cumulative training package for various segment of staff with the hospital.

The Federal Emergency Management Agency (FEMA), has many health, medical, and hospital specific trainings.  FEMA has made generic course specific to health and medical professionals.  For instance, Incident Command Systems (ICS) 100 is a course that many involved in emergency management take to understand the structure and principles of emergency response.  FEMA has taken the generic course and tailored the content to hospitals and healthcare.  Introduction to the ICS for Healthcare/Hospitals (IS-100.HCb) is approximately three hours and is a self-paced, online training aimed towards physicians, nurses, and staff working in materials/resource management, security/safety, laboratory, radiology, and inter-facility transport (Federal Emergency Management Agency, 2015).

There are many national institutes and organizations that provide trainings in many forms.  A national leader in providing hospital emergency planning training is the Center for Emergency Preparedness and Disaster Response at Yale New Haven Health.  Course cover a range of topics to include the Joint Commission/Centers for Medicaid and Medicare Services (CMS), National Incident Management System (NIMS), Occupational Safety and Health Administration (OSHA), special populations, radiation, biological/infectious diseases, behavioral health, mass fatality, and healthcare compliance (Center for Emergency Preparedness and Disaster Response at Yale New Haven Health).  The trainings are targeted to hospital, healthcare and public health workers.

The Center for Emergency Preparedness and Disaster Response offers two trainings specific to evacuation.  Emergency Management (EM) 150 – Introduction to Evacuations examines the approaches to evacuation, recognizes events that cause the need to evacuate, and discusses concerns related to the monumental task (Center for Emergency Preparedness and Disaster Response at Yale New Haven Health).  The second course is EM 151 – Patient Movement During Evacuations.  This course identifies specific challenges when conducting evacuation and provide guidance on staffing to patient ratios, proper movement techniques, and transportation options (Center for Emergency Preparedness and Disaster Response at Yale New Haven Health).  Both courses are available online and take sixty minutes to complete.  The online courses provide a great introduction to topics and can be followed up with exercises to increase efficiency.

Exercises

Exercises allow for plans and concepts to be operationalized to gauge their effectiveness. Taking ideas, plans, processes, and training to fruition by simulating probably scenarios allows for immediate validation and feedback.  This allows for technical and managerial skill development while letting the individual know how they are likely to react to stressors (Sinclair, Doyle, Johnston, & Paton, 2012).  Lessons learned observed by the participant and observers will allow successes and challenged to be captured and adjustments made pre-disaster.

Little research has been conducted on exercises for hurricane evacuations.  Research conducted on exercises within hospitals and medical centers focus on specific events, and not the overall program.  Hunter, Yang, Petrie, and Aragon (2012) look at the framework from a California state-wide exercise to gage participants’ feedback to create a new framework to be implemented in the preparedness phase (Hunter, Yang, Michael Petrie, & Aragón, 2012).  The exercise scenario generated mass casualties from an improvised explosive device and did not include any evacuation.

Regardless of the event and actions, the study found that an overarching problem was the inter-organizational communications using the existing framework (Hunter, Yang, Michael Petrie, & Aragón, 2012).  Surveys reached 35 local health departments (LHDs), 24 local emergency medical services (EMS) agencies, 121 hospitals, and 5 Regional Disaster Medical and Health Coordinators/Specialists (RDMHC) (Hunter, Yang, Michael Petrie, & Aragón, 2012).  The conclusion of the study found the complexity of overlapping authoritative organizations contributed to confusion in communications.  Additional factors include staff that perform emergency duties as a secondary function and operating in emergency operations centers with other agencies (Hunter, Yang, Michael Petrie, & Aragón, 2012).  Hunter, et al. (2012) recommend that work should be completed in the preparedness phase to help address the inter-organization communication issues by heling clarify expected and actual organizational roles, responsibilities, and resource capacities in the medical and public health structure (Hunter, Yang, Michael Petrie, & Aragón, 2012).

An overview and after action review was conducted of a hospital evacuation exercise at Cincinnati Children’s Hospital.  The exercise lasted one hour and was conducted prior to any surgeries to minimize the impact on scheduled patients.  The pediatric level I trauma center with 525 beds and more than 12,000 employees had conducted training and exercises in segmented departments, but had never conducted a hospital wide evacuation exercise (Baioni, Gneuhs, Dickman, Weber, Hueneman, Timm. July 2013).  The exercise was performed in a control environment that allowed hospital staff to demonstrate department plans and procedures in a collaborative manner with situation injects.

Evacuation Guidance

Guidance is the advice or information intended to resolve a problem or difficulty. Guidance originates from a source that has extensive knowledge on the topic and provides advice as an authority figure or organization.  Hospital evacuations are complex and involves many stakeholders.  The identification of roles and responsibilities, methods of communication, and pre-identified actions drives the efforts for producing plans and procedures consistent with standards from authoritative experts.  Guidance is intended to be a tool to help implement standard accepted practices and procedures in a manner that can be duplicated with ease.

No research has been conducted related to the effectiveness of hospital evacuation guidance.  Evacuation guidance exists from many authorities to include the Agency for Healthcare Research and Quality (AHRQ) within the U.S. DHHS.  The AHRQ is charged with supporting research designed to improve the quality of healthcare, reduce its cost, address patient safety and medical errors, and broaden access to essential services (Agency for Healthcare Research and Quality, 2010).  The Hospital Evacuation Decision Guide focuses on evacuation efforts into three time frames; pre-disaster, pre-event, and post-event.  Each has unique areas and concerns that required consideration and collectively build to make a comprehensive approach to create a plan.

The pre-disaster self-assessment guides the user through examining critical infrastructure. This includes water, steam, natural gas, electricity, boilers, life support equipment, health information technology, telecommunications, and security (Agency for Healthcare Research and Quality, 2010).  Understanding how critical infrastructure functions within the hospital is critical to keep the vital services operating during an emergency.  Each identified function requires redundancy or alternative methods to ensure care of patients remain uninterrupted.  Addressing an issues or concern in the pre-disaster phase of the assessment allows for procedures and protocols to be established prior to an incident.

The guide also addresses estimating evacuation time.  There are many factors to developing a realistic evacuation time that allows for plans to be developed.  A key factor is understanding the number of patients and patient acuity mix.  Identifying what patients are ambulatory and not, while understanding that specific numbers fluctuate on a daily basis. Knowing specific patient information leading up to a potential disaster, such as a hurricane, allows for generic plans to be updated with current census information.

Staffing levels can cause major implications during hospital evacuations. The correct staff, with the right skills, is needed at both the hospital conducting evacuation and the receiving care provider.  Timing of operations and understanding what staff is needed prior to the disaster is crucial.  Hurricanes are notice events, meaning precursory information about the threat will be known in advance.  Hospital leadership has the ability to conduct staffing adjustments and make operation decisions based on current forecasts.  A pre-disaster self-assessment should consider personnel policies, potential staffing shortfalls, and alternate staffing options for the most critical functions (Agency for Healthcare Research and Quality, 2010).  Staff should be notified as early as possible to ensure they can plan for their family and personal affairs to ensure they can perform their duties when required.

Hospital evacuation require specialized resources for transportation.  The Hospital Evacuation Decision Guide suggests conducting a Self-Assessment Worksheet that includes an estimate of the number, or percentage, of patients requiring special transportation to other facilities (Agency for Healthcare Research and Quality, 2010).  Transportation resources go beyond the vehicles and include the required accompanying staff, equipment, and supplies. Arrangements made with transportation providers prior to the disaster increases the likelihood that they will be available when needed.  Hospitals should ensure that multiple providers are identified to ensure that evacuation operations can continue if a provider is unable to provide the requested transportation resources.

Estimating the time needed to evacuate a hospital can be challenging.  The Hospital Evacuation Decision Guide provides four possible approaches.  The first approach is to find a comparable hospital that has evacuated before under similar circumstances and use their time as the estimated total for planning.  The second approach is to conduct an evacuation tabletop exercise that mirrors a full scale evacuation.  Using the estimated time generated from the exercise provides a realistic estimate without conducting a large full-scale exercise.  The third approach is a computer model that simulates a scenario with various factors that computes an estimated evacuation time.  Lastly, a calculation can be made from planning how many round trips are needed to the alternate care facility to evacuate the patients in care.  Multiplying the time required by the number of patients and adding additional time for transporting patients to the staging area can total an estimated evacuation time.  This approach allows the hospital to calculate the total time working backwards.

The second time phase to the Hospital Evacuation Decision Guide covers the pre-event evacuation actions.  A pre-event evacuation is appropriate when hospital leadership believe the hurricane may cause damage resulting in unacceptable risk to patients and staff, or when the damage from the storm will result in conditions that would make future evacuation impossible or dangerous (Agency for Healthcare Research and Quality, 2010).  Gauging risk and potential dangers for future disasters is not easy.  Hospital leadership have to carefully conduct assessments and reassess the current forecast and projections to develop a timeline for decisions. The wait-and-reassess option is time limited.  As the conditions deteriorate, patients will not be able to be evacuated safely due to hurricane force winds or impassable roads.

Timing is a key component for leadership to decide to evacuate or shelter-in-place. The AHRQ, review of literature, and expert interviews, all confirm that the most common decision during the approach of an Advance Warning Event is to shelter-in-place (Agency for Healthcare Research and Quality, 2010).  Recent hurricanes have shown that evacuation of hospitals prior to hurricane landfall is more common than historic examples (Agency for Healthcare Research and Quality, 2010).  Local emergency management and government leadership should be used to help verify potential impact and can help coordinate support for either evacuation or shelter-in-place.

Post-event evacuation occurs with no-notice events or after impacts from disasters result in more damage that projected.  Hospitals should prioritize patients when conducting evacuation with the most resource-intensive patients to be the first leave (Agency for Healthcare Research and Quality, 2010).  Additional challenges could occur to constraints on resources, ambulance, and accessibility to alternative care facilities.

The U.S. DHHS is not the only agency to produce hospital evacuation guidance. Guidance can come from other federal, state, and local government agencies, non-profit, and professional organization.  The Florida Department of Health produced the Hospital Emergency Evacuation Toolkit, supporting hospitals within Florida to create evacuations plan.  However, the toolkit does not provide a complete set of procedures that can be used during an evacuation. Preparedness, planning, training, and exercises are needed to support the development of an evacuation plan and program that benefits the hospital and ensures the continuing care for patients.

The Hospital Emergency Evacuation Toolkit, produced at the state level, provides guidance for a smaller audience.  National guidance is written to be generic enough that allows for adaptation to various geographic areas.  State and local guidance can identify unique issues and concerns that national guidance is not able to.  State and local laws can be included to create a better resource for providers to use.

The toolkit covers many areas that the U.S. DHHS guidance does, but at a more detailed manner.  The Introduction section provides and overview of state and federal authorities, evacuation triggers, ethical issues, and possible evacuation timeline.  The guidance provides useful information on trigger points, a decision point that requires action within a defined time to ensure the safe execution when facing damaging impacts from a threat (Florida Department of Health, 2011).  Pre-identifying trigger points in the preparedness phase reduces possible disagreement between hospital leadership neglecting to make decisions.

Addressing ethics in hospital evacuation is important.  It is not an easy decision for leadership to make.  The decision to shelter-in-place verses evacuate is a life or death decision (Florida Department of Health, 2011).  The decision to evacuate is considered from an ethical, medical, and economic viewpoint with the goal of ensure the best care for patients and ensuring safety of staff.

The scope of evacuation section includes preparedness elements.  This section covers types of evacuation, creating a comprehensive plan, hospital incident command system, notification, and communication with state and local authorities.  This section identifies multiple options related to evacuation.  Evacuation does not exclusively refer to a full emptying of a hospital.  If only only one building on a hospital campus is damaged, there may be only a partial evacuation to an alternate care site or undamaged building on campus.

The coordination with stakeholders is extremely important.  A hospital should coordinate their plans with local and state health partners.  Coordination with partners allow for an understanding of what actions will be taken prior to an event occurring.  Local and state health departments knowing the alternate care location for hospitals before an evacuation occurs allow for better coordination of support and resources.

Section three covers facility issues.  A hospital can contain one or many buildings making up a campus.  Coordinating multiple buildings into a comprehensive evacuation plan can be challenging.  Each building should have an individual plan that correlates to the comprehensive plan for the hospital campus.  The identification of primary and alternate staging areas is needed to ensure staff are aware of their locations.  Pre-determined routes from buildings to staging areas allow for emergency planners to use realistic evacuation time estimate and determine appropriate resources that are needed.

Patient and staff considerations is section four.  Creating a system for prioritizing patients prior to a disaster will help expedite the evacuation process.  Categorizing patients into triage levels identifies what resources, both equipment and personnel, are needed using a strategic process.  The categorization of patients into triage levels should be done prior to evacuation and not once the evacuation process has started.

There are multiple strategies on the prioritization of patients and the sequence that they should be evacuated.  Table 1, Evacuation triage level and evacuation order, shows two methods for evacuations once patients are categorized.  The reversed start priority begins evacuating patients that need minimal assistance to be transported to the staging area.  These patients are coded green because of the minimal support needed to transport.  Once all patients that were marked green are moved to the staging area, the next triage level is yellow, patients that require some assistance, possible one to two staff, to be transported to the staging area.  The last triage level to be evacuated are the patients that require the most support and are coded red. These patients require two to three staff because of their inability to move themselves or having a mobility injury.  The traditional start priority evacuation is the exact opposite of reversed start priority.  The traditional start priority starts with the most complex patients first and moves toward the most transportable patients being the last to evacuate.

Table 1 – Evacuation triage level and evacuation order

Triage Level	Priority for Evacuation of Patient Care Units   REVERSED START PRIORITY	Priority for Transfer to Another Healthcare Facility   TRADITIONAL START PRIORITY
GREEN – GO	These patients require minimal assistance and can be moved FIRST from the unit. Patients are ambulatory and 1 staff member can safely lead several patients who fall into this category to the staging area.	These patients will be moved LAST as transfers from your facility to another healthcare facility.
YELLOW –CAUTION	These patients require some   assistance and should be moved SECOND in priority from the inpatient unit. Patients may require wheelchairs or stretchers and 1-2 staff members to transport.	These patients will be moved SECOND in priority as transfers from your facility to   another healthcare facility.
RED – STOP	These patients require maximum assistance to move. In an evacuation, these patients move LAST from the inpatient unit.   These patients may require 2-3 staff members to transport.	These patients require maximum support to sustain life in an evacuation. These patients move FIRST as transfers from your facility   to another healthcare facility.

Hospital evacuation equipment is section five of the Hospital Emergency Evacuation Toolkit.  Conducting an assessment of equipment needed to implement a hospital evacuation is an important element of the planning process.  Conducting evacuation operations with the right equipment will ensure operations will not be impacted.  Considerations for pediatric and elderly patients are needed so specialized equipment is on hand prior to a disaster. Alternate transportation options between floors need to be identified if evacuation occurs after hurricane landfall and the hospital loses power.

Planning for medical information and records is the next section.  Patient medical history and current charts will be required for the alternate care facility.  The toolkit suggest that records should include copies of medication administration sheets, most recent set of complete medical orders, latest lab reports, Do Not Resuscitate (DNR) orders, advanced directives, restraint orders, and receiving physician authorization papers (Florida Department of Health, 2011).  There are many medical programs that allow for records to be transferred electronically, however they could be impacted during and emergency.  Hospitals should ensure that paper records can quickly be used if electronic records systems are down and cannot be accessed.  Identifying alternate care facilities allows for procedures to be established prior to a disaster.

Supplies during a hospital evacuation are critical to ensure that resources are available to implement the complex plan.  The environment during an emergency operation can cause simple task to become more complicated.  The ability to purchase equipment and supplies with minimal notice can be difficult.  Supplies can be limited before a hurricane makes landfall because people panic.  Sourcing suppliers prior to a disaster is important.  Setting up business accounts with multiple vendors increase the ability to purchase supplies when needed.  Relying on a single source for supplies and resource increases chances that essential items cannot be acquired during challenging situations.

The eight section of the Hospital Emergency Evacuation Toolkit is support services.  This sections helps highlights important segments that does not fit in previous sections.  This includes logistics, materials management, medical asset management, transportation, needs during transport, and water and fuel (Florida Department of Health, 2011).  Each element is important part of the toolkit and makes an evacuation plan comprehensive.

The last section focuses on re-entry and return.  Evacuating from a hospital means there is likely a threat of damage to the structure.  Safety is paramount in ensuring that it is safe to reenter and care for patients. Inspectors should conduct a walkthrough to ensure the structure is not damaged.  The toolkit suggests that at a minimum the areas required for inspection include systems that provide: safety; security; sanitation; electrical distribution; compressed gases; and heating, ventilation, air conditioning (HVAC) (Florida Department of Health, 2011).  Hospital staff should enter the facility when order to by hospital leadership.  Once the hospital is able to safely care for patients, the coordination should begin to receive the previously evacuated patients if still required.

The U.S. DHHS and Florida Department of Health emergency evacuation guides and toolkits provide a comprehensive approach to producing a hospital plan.  Tools and resources from authoritative agencies and organizations provide a valuable resource for hospitals to approach the complexities of conducting an emergency evacuation.  It is a daunting task and having the resource available allows for ease in adaptability.

Legal Requirements

Evacuation orders for hurricanes can complex.  Various laws, requirements, and statutes exist in defining the authority of government at the federal, state and local level.  Individuals that have responsibility to make evacuation orders have among the most challenging and complex decisions to be made during disasters (Fairchild, Colgrove, & Moser Jones, 2006).  There are ethical, economic, and political considerations that required to be considered during a time of uncertainty.  There is not a guarantee on what will or will not happen.

The federal government has the authority to support states during a disaster when requested by a state (Fairchild, Colgrove, & Moser Jones, 2006).  The state can request federal assistance when the required assistance is beyond the capabilities of the state.  This allows for a formal process for support that is the foundation to emergency management.  All responses are local.  If local resources cannot meet the demand to respond to an incident, support can be request to the next level above.  This may be the county or state level.  If the resources are depleted or do not exist at that level, a request can be made for support to another state or the federal government.  This approach allows for control at the local level and a structure for filling request in a coordinated manner.  Additionally, this process generates delineation between authorities in government.  This concept stops the federal government from overstepping boundaries when not requested.

The authority to direct a mandatory evacuation is dependent on the location.  State and local laws vary throughout the United States.  There is not a current federal statute that allows for the federal government to order a mandatory evacuation from natural disasters.  States have the ability to create and enforce legislation related to mandatory evacuations.  States can specify if the person responsible for giving an evacuation order is the governor, local government, or both (Fairchild, Colgrove, & Moser Jones, 2006).  Each option assigns responsible that is appropriate for the designated state.

Federal courts have recognized that state and local governments have the authority the force evacuation is life threatening emergencies (Fairchild, Colgrove, & Moser Jones, 2006). Even with case law on the side of the authoritative designated official, there are ethical and moral considerations.  Mandatory evacuations may create a burden on families that may not have resources available to obey the order.  Local and state governments need to identify support for all citizens to evacuate within their jurisdictions.

Accreditation Requirements

There are no existing studies related to hospital accreditation and hurricane evacuation. Accreditation is the process to be award certification from an organization for meeting or exceeding a set of standards focused on improving a specific market or field.  Hospitals have to meet federal, state, and local licensing requirements set in legislation and policy.  Hospitals that seek to gain accreditation from an accrediting body looks to go above and beyond the legal requirements.  Seeking accreditations demonstrates that the commitment to safety and quality of care.

The Joint Commission on Accreditation of healthcare Organizations is the nation’s largest and oldest standards-setting and accrediting body in health care (The Joint Commission, 2017).  More than 21,000 health care organization and programs in the United States are accredited and certified by the Joint Commission on Accreditation of healthcare Organizations.

The organizations include hospitals that provide ambulatory and office-based surgery, behavioral health, home health care, laboratory and nursing care center services (The Joint Commission, 2017).  Each organization that is accredited and certified are required to meet standards aimed at patient safety and standard of care.

The Joint Commission on Accreditation of healthcare Organizations has a set of standards for emergency management.  There are seven standards that address segments of emergency evacuation and coordination.  Emergency management 02.01.01, element of performance (EP) 2 states that hospitals must have an emergency operations plan (EOP) that includes both staged and total evacuation (The Joint Commission, 2016).  Staged evacuation is the orderly evacuation in phases to minimize further road congestion and travel times to other facilities (Florida Department of Health, 2011).  A total evacuation means all individuals evacuate simultaneously when initially notified.  Evacuation planning allows for minimizing the evacuation time and to maximize number of evacuees (Jafari, Golmohammadi, & Seyed, 2008).  The specification of two distinctly different evacuations allow for each to be addressed individually while being incorporated into a comprehensive plan.

Emergency management 02.01.01, EP 7 cites that the EOP must identify alternative care sites that meet the needs of the hospital’s patients (The Joint Commission, 2016).  Alternate care sites should be close enough that ground transportation is a viable option to move patients, but far enough geographically that the same threat exists at both locations.  Alternate care facilities should have comparable capabilities to the hospital evacuating.  Hospitals should not identify just one alternate care facility, but pre-identify multiple options in various locations.  Identifying multiple care facilities allows for hospitals to spread out patients to multiple care facilities.

The process and structure for communicating during disasters is defined in EM 02.02.01, EP 13 (The Joint Commission, 2016).  Communication with internal and external stakeholders is vital to the success of an evacuation.  The Hospital Incident Command System (HICS) is the standard for clarifying reporting structures and roles within an emergency operation.  Internal communications are often the primary concern and addressed during the planning, training, and exercises for emergencies.  Existing structures for other hazards and emergencies can be used for an evacuation.  External communications are the primary concern for hospitals during an evacuation.  External partners, such as police, fire, emergency medical services, and public health officials, may be regular partners to hospital administration, but the list should go beyond routine partners.  Maintaining a regularly updated resource directory that contains external agencies will assist in rapidly identifying contact information (Florida Department of Health, 2011).  Communications during an emergency are complex and minor confusions and misunderstanding has the ability to cause widespread concerns and issues.

The fourth emergency management standard that requires hospitals arrange for transportation of some or all patients, medications, supplies, equipment, and staff to the alternate care facility is found in EM 02.02.03, EP 9 (The Joint Commission, 2016).  The level of care that patients require dictates the additional transportation needs.  Resources and supplies should be transported with patients to support the receiving care site incase supplies are not on-hand.

The movement of pertinent information patient information to alternative care sites is cited in EM 02.02.03, EP 10 (The Joint Commission, 2016).  Medical records provide a history of vital health information that should stay with the patient until being discharged (Florida Department of Health, 2011).  Medical records can be electronic or paper based.  Regardless of the format, a process is required to ensure the transmission of documents occurs in a timely manner that does not lag behind the movement of the patient.  Procedures should be included in the plan with an alternative means identified.

The sixth standard directs the hospital to communicate, in writing, with each of its licensed independent practitioners regarding his or her role(s) in emergency response. Additionally, the written notice must include reporting structure during the emergency operations.  This is identified in EM 02.02.07, EP 8 (The Joint Commission, 2016).  Reporting structures can change during emergency operations from traditional operations.  Understanding the environment of emergencies and protocols for duties and responsibilities ensures that evacuations are conducted with maximum efficiency.  Some staff may be pulled from their primary duties to help in transporting patients (Agency for Healthcare Research and Quality, 2010).  This will reduce the number of staff that care for patients and increase their ratios for evacuation operations to remain active. Additionally, each position should be rostered to have a primary and alternate to allow for flexibilities to ensure positions are filled at all times.

The last standard related to evacuation is how the hospital will evacuate when the environment cannot support care, treatment, and services.  This is found in EM 02.02.11, EP 3. This standard is the culmination of all previous standards into an executable plan.  Pieces from each standard funnel into the how the hospital will evacuate.  Areas that describe the how to accomplish evacuation include categorizing of patients, roles and responsibilities, resource allocation, communications, patient record management, and notification of external partners.

Existing Models

Suggestive models for hospital evacuations have been studied and examined in-depth looking at specific issues and concerns.  Models provide a structure that can be reproduced for other users to use in planning, response, and recovery.  Studies related to models for hospital evacuations are founded by research.  The conclusions and recommendations should be considered by hospitals that have or are in the process of creating a hospital evacuation plan.

The research is sporadic and not inclusive to a specific model that is the standard for hospital evacuations.  The four models looked at various aspects of evacuation, each important, but lack a comprehensive assessment.  The research focused around models in support of decision making support, determination of risk, impacts of traffic and time windows, and conducting evacuation operations without electrical power.

Evaluating risk is an important part of building an evacuation plan. Becker, Brenes, Hatcher, and Taaffe (2007) examine the risk associated with not only making the decision to evacuate a hospital, but reducing the risk when conducting the evacuation process itself (Becker, Brenes, Hatcher, & Taaffe, 2007, January).  The process of evacuating a hospital includes multiple partners, movement of critical care patients, and other external elements.  As the number of people and the steps needed to evacuate a hospital increase becoming more complex, the risk for conducting operations in a safe and efficient manner is increased (Becker, Brenes, Hatcher, & Taaffe, 2007, January).  Understanding risk at various points within the decision making process is important to address.

The study looked at calculating risk based on six factors.  Each factor contributing to the overall risk from the current situation related to the evacuation.  The authors created a calculation for risk using the occupancy percentage of the hospital, percentage of available contracted vehicles, percentage of available nurses, average age of equipment, training of hospital employees, and proximity of the hurricane.  The objective of the equation is to give a qualitative variable to the value of risk (Becker, Brenes, Hatcher, & Taaffe, 2007, January).  Each risk factor is assigned a designated rating allow for a value to be entered into the equation for the cumulative risk.

Becker, Brenes, Hatcher, and Taaffe (2007) conclude that the risk equation is only a piece of the hospital evacuation process.  They do not provide any examples of using the tool, rather giving an opportunity for hospitals to use the equation and tailor the contributing factors to their specific situations.  The research is valuable to take the perception off risk and making it a numeric value that can be measured by including multiple factors.

The proposed equation from Becker, Brenes, Hatcher, and Taaffe should be built into the concepts of the study conducted by Bish, Agca, and Glick (2014) on decision support.  The study on decision support develops and tests an evaluation model that focuses on minimizing expected risk (Bish, Agca, & Glick, 2014).  The Hospital Evacuation Transportation Model (HETM) is developed by calculating the total risk for evacuation by including the risk from the event with the risk by conducting the evacuation operation for patients and staff.  Two transportation options, ambulance and ambulance/bus, are examined and incorporated into the model.  The authors suggest that since hospitals practice reducing risk each day the model requires a risk minimization objective.

The model is tested against three threat risk scenarios that covering varying duration. First, the model is tested in a constant scenario, in constant time, then a linear scenario, and finally an exponential scenario.  In addition to the threat risk scenarios, the model categorizes patients into nine types and three risk groups.  Patient types 1-3, the most critical patients, are categorized into Risk Group (RG1), patient types 4–6 are in Risk Group 2 (RG2), and patient types 7–9, the least critical patients, are in Risk Group 3 (RG3) (Bish, Agca, & Glick, 2014). Categorizing patients allow for variables to be included in the cumulative scenarios to test the models.

The model is tested using the Carilion Medical Center (CMC), the second largest hospital in Virginia.  The CMC is a 765-bed primary care hospital combined with a 60-bed Level

III Neonatal Intensive Care Unit (NICU) (Bish, Agca, & Glick, 2014).  Applying the model to a hospital allows for immediate feedback as a method of quality control.  The simulation confirmed that the HETM can help in both preparedness and operations of hospital evacuations to utilize the appropriate transportation methods with patients while minimizing risk (Bish, Agca, & Glick, 2014).  This research and model development goes beyond introducing a concept, model, or equation without testing the proposal.  The authors went one step further and verified the benefit.

A study conducted by Tayfur and Taaffe (2009) provides a stochastic model to address an advanced-notice evacuation event like a hurricane.  The model entails categorizing patients into three categories, vehicles into three categories, and nurses into two locations and three skill sets (Tayfur & Taaffe, 2009).  Additionally, the model involves operations policy considerations for patient actions to either releasing the bed, transporting patient into staging area, or placing the patient onto vehicles for immediate transport to alternate care site.  Finally, the model projects cost estimates into the model.  Staff at various skill levels and type of transportation resource is calculated at hourly rates to provide a financial component for planning considerations.

The study by Tayfur and Taaffe (2009) finds that total evacuation cost does decrease as the total available time to complete the evacuation is increased (Tayfur & Taaffe, 2009). Simulations show that evacuations made with the 42-hour landfall timeline generated additional cost partially to negative impacts from traffic competition adding time to predetermined routes (Tayfur & Taaffe, 2009).  This is extremely valuable for hospitals to understand when deciding when to make decisions and building trigger points into evacuation plans.

The last model study looks at specific challenges related to losing electric power while conducting a hospital evacuation.  The loss of power causes cascading effects that make ever task more challenging.  The study incorporates a case study from a 2001 evacuation of Memorial Hermann Hospital in Houston, Texas. Vugrin, Verzi, Finley, Turquist, Griffin, Ricci, and Wyte-Lake (2015) use a model designed to track the cascading events from power loss and to identify the staff, resources, and operational adaptations required to sustain patient care and/or conduct an evacuation (Vugrin, et al., June 2015). The recognition of going beyond a full scale hospital evacuation and adding a complex variable builds a complex environment.

The model is based on two primary components: a patient care hierarchy and a constrained optimization model.  The patient care hierarchy represents the complex structure of dependencies of patient care upon resources and care from the hospital (Vugrin, et al., June 2015).  The constrained optimization model is a formula that compares the patient care requirement to hospital resources throughout the projected duration of power loss (Vugrin, et al., June 2015).  The model is tested in two scenarios with determined assumptions causing various challenges.  Scenario one uses the exact information from the Memorial Hermann Hospital from 2001.  This scenario was reactive in nature.  The second scenario uses the same assumptions, but adds a preparedness element.  Prior to hurricane landfall, hospital administrators predict that the hospital is likely to lose power for up to 12 hours.  This scenario allows a comparison for the same setting to be examined from a responsive and preparedness viewpoint.

The study found that decisions made on timing of evacuations have a significant impact on the length of time required to evacuate (Vugrin, et al., June 2015).  Planning for potential disruptions, rather than assuming everything will go perfect during an emergency, can benefit the hospital evacuation plan.  The study generates evidence for hospitals to consider when conducting emergency evacuation plan development or revision.  The research is beneficial as should support other models in a comprehensive approach to conducting evacuation guidance.

The four studies on model recommendations for hospital emergency evacuation produce recommendations that constitute consideration for existing or future plans.  Model logic produces a means to gauge scenarios that test policies and plans in a quantitative manner.  The use of models provides support to the large comprehensive approach to emergency evacuation planning.

METHODOLOGY

Research Design

Research will be conducted by using a case study approach.  The qualitative study using a comparative analysis with focus on specific examples by examining actions taken by hospitals. The two homogenous cases used in the research will be Hurricane Katrina and Hurricane Sandy. The two cases are different and similar in many ways, but provide an opportunity to analyze the two most destructive hurricanes in recent history.  The data and analysis of hospital actions will provide a cohesive assessment from samples that differ geographically.

Qualitative research allows the researcher to examine the subject in-depth.  The study will not include interviews, rather pull data from existing research and documents provided on each sample.  Samples used in the case study will be compared to standards identified by The Joint Commission on Accreditation of healthcare Organizations related to emergency preparedness, response, recovery, and evacuation activities.  These standards are national recognized as the standard and used to accredit and certify 21,000 health care organizations across the United States.  The Commissions requirements around emergency planning are precise and developed over years of experience.  Requirements include emergency planning focused on maintaining operations and evacuation to an alternate care location.

Sample

Each case will include two sub-units, number of hospitals, to increase the reliability and validity to the research.  This layer design will allow research to look at specific actions and results from decisions made for hospitals.  The Louisiana Hospital Emergency Preparedness and Response Emergency Operation Plan provide a comprehensive list of hospitals throughout Louisiana.  Hospitals are broken into eight regions allowing for optimal control of the state health infrastructure.  Regions 1 and 3 are the southern-most regions and include New Orleans and surrounding communities.  A total of 26 hospitals from region 1, and 17 hospitals from region 3, were compiled into an Excel spreadsheet.  A random sampling function formula was entered to select the samples. Table 1 lists the 43 hospitals and the sample order.  Starting at the beginning of the randomly selected hospital list, a search was conducted using the Summon Academic Library to determine the action they took, i.e. shelter-in-place or evacuate patients. This process would be repeated until one hospital was selected for each action.  The first sample that was selected was twelve, corresponding to Ochsner Medical Center (known as Memorial Medical Center in 2005).  Memorial Medical Center did not evacuate before Hurricane Katrina and is labeled Sample 1.  The second randomly selected hospital, Lady of the Sea General Hospital, did not evacuate and was passed as a chosen sample for the case study.  This was repeated for the third randomly selected number, Select Specialty Hospital.  The forth randomly selected hospital, Saint Charles Parish Hospital did evacuate their patients prior to Hurricane Katrina and retains the designation of Sample 2.

The hospital list from Lessons Learned from Hurricane Sandy and Recommendations for Improved Healthcare and Public Health Response and Recovery for Future Catastrophic Events by the American College of Emergency Physicians was used to provide a list of hospitals in New York City.  A random sampling function formula was entered to select the samples.  Table 2 shows the list of hospitals and sample order.  Starting at the beginning of the randomly selected hospital list, a search was conducted using the Summon Academic Library to determine the action they took, i.e. shelter-in-place or evacuate patients.  This process would be repeated until one hospital was selected for each action.  The first sample that was selected was seven, Bellevue Hospital, which had not evacuated prior to Hurricane Sandy and will be labeled Sample 3. The second randomly selected number was five, North Shore Health System/Long Island Jewish Hospital, which did not evacuate before the storm.  The next randomly selected number was two, New York Downtown Hospital, which did evacuate patients prior to Hurricane Sandy, and will be labeled Sample 4.

The samples may vary in size and capabilities, but resemble two hospitals that chose different paths when facing the same hurricane.  There were many hospitals that were impacted during each hurricane within the immediate geographical area, of which these hospitals were selected at random from a list of hospitals that were impacted by each hurricane.  Once a hospital was selected it was verified what action they took during the event.  Once a determination was made on the hospital action, a second random hospital would be selected, and repeated, until a hospital was identified that chose the counter action.

Data Collection

Data will be collected from multiple sources.  There are many studies, after-action reports, scholarly articles, and professional organization that examine segments of the current study.  A search will be conducted using the Summon Academic Library and the Department of Health and Human Services, Technical Resources, Assistance Center, and Information Exchange (TRACIE), for each segment of case study.

The results from the searches generated a mix of scholarly articles, case studies, after-action reports, disaster planning, response, and recovery templates, and editorial stories.  The criteria for source selection are the relevance to specific topic of case study.  Each source will be categorized into specific groups for future use.  Categories include Hurricane Katrina, Hurricane Sandy, Memorial Medical Center, Saint Charles Parish Hospital, Bellevue Hospital, New York Presbyterian Lower Manhattan Hospital, New York, and Louisiana.

Hurricane Katrina and Hurricane Sandy are both well researched and studied.  Data was collected on each phase of the research.  The primary data sources for background information on hospital capabilities are after-action reports, professional documents that assessed capabilities of hospitals, and scholarly research. Historic hurricane information that details the characteristics and path are abundant. Hurricane information came come from multiple sources. The data on the impact on selected hospitals will come from scholarly studies and articles from individuals that were present during the event. Many include interviews that allows this study to bypass conducting interviews to accomplish the same results.

After-action reports provide a comprehensive assessment of how a specific function occurred during an event. These reports, from various authors looking at segments of the research, will depict people and organization analysis of operations. After-action reports will be a primary source of information to account for the assessment and impact on operations from the hurricanes.

Analysis

The research will occur in four phases.  First, an assessment will be conducted on hospital status prior to hurricane landfall.  Data elements will include bed capacity, presence of emergency plans, staffing levels, secondary power source, and experience conducting exercises. This phase will provide a baseline for future phases of the case study and allow for final comparison to other hospital care facilities.

The second phase will focus on the elements of the hurricane. This phase will look at the characteristics of the storm, preventative actions or orders given by the state or city, and political or leadership influence.  The history of the hurricane will allow for an understanding of potential considerations for the decision that hospitals will make in the future operations.  The history of the hurricane is important to examine and understand to create the

The third phase of the assessment will look at decision made by each hospital to either shelter-in-place or evacuate.  This phase allows for an analysis on various factors on why decisions were made in reference to their capabilities prior to the hurricanes landfall.  Also, the changing elements of the hurricane helps paint the picture and recreate the threat throughout the actions taken by hospitals.

The last phase will provide an opportunity to examine the actions that were taken and their impact to operation.  This phase will allow for comparison between hospitals and analyze the impact that their decisions made when facing the threat from the hurricane.  This phase will examine the impact on operations, time required to regain full operations, impact on staffing levels, and impact on power or other damaging factors.  Once all hospitals are assessed a comparison will be made to the countering action hospital.  This will allow for a final assessment to be made to develop a conclusion on the appropriate action that best cares for the patients, ensure staff safety, and continues to serve the impacted communities.

Limitations of the Study

This study is founded by a qualitative analysis of existing research, after-action reports, studies, and scholarly articles that followed the devastating impacts of Hurricane Katrina and Hurricane Sandy on hospitals.  The research will provide a detailed structure to conduct an analysis on surrounding factors that influenced decisions made by those in leadership positions with the authority to decide to shelter-in-place or evacuate.  However, the study is limited by not conducting direct interviews with those leaders that could provide direct answers for their actions. Previous interviews by these individuals have been cited

The study will be based on the authors interpretation of the data collected in the study. There are many factors that must be considered when hospital leadership determines the most appropriate actions that should be executed.  A comprehensive list is used in the study, but could unintendedly exclude additional factors.  There is no way to understand the exact situation unless you were present.  All efforts will be made to ensure that research is focused on factual information and not by drawing conclusions.

RESULTS

Hospital Preparedness - Katrina

Prior to Hurricane Katrina, a unique emergency management preparedness effort was underway for the Southern Louisiana area.  The Federal Emergency Management Agency (FEMA) awarded a contract to Innovative Emergency Management Inc. (IEM) to lead the Southeast Louisiana Catastrophic Hurricane plan to “develop a functional, scenario-based exercise that would drive the writing of Incident Action Plans and build the foundation for Functional Plans” (Beriwal, 2006).  The basis for this effort was focused on a scenario that would drive planning with stakeholders from a computer simulation of a slow moving Category 3 hurricane hitting Southern Louisiana.  The storm would be called Hurricane Pam.

Hurricane Pam was modeled as a strong, slow-moving Category 3 storm that would produce 20 inches of rain, significant storm surge, sporadic tornadoes, and resulting in 10 to 20 feet of water within New Orleans (Beriwal, 2006).  A key factor to Hurricane Pam is the fact that Hurricane Pam was a slow moving storm. This allows for additional rainfall over a geographic area producing greater storm surge.

The projected impact for Hurricane Pam assumed that over 55,000 people would seek shelter prior to landfall, the 20 inches of rain and storm surge would force water over levees resulting in the City of New Orleans to be under 10-20 feet of water, and over 1.1 million Louisiana residents to be displaced (Beriwal, 2006).  The catastrophic flooding would leave parts of southeast Louisiana uninhabitable for more than a year (Select Bipartisan Committee to Investigate the Preparation for and Response to Hurricane Katrina, 2006).  The long-lasting damage from a hurricane that delivers considerable water levels across creates major implications for the recovery effort.  Resources would be scarce for those able to rebuild in areas after the water recedes.

A major concern with the simulation was the assumption that 300,000 people would not evacuate in advance leading to a large search and rescue operation (Select Bipartisan Committee to Investigate the Preparation for and Response to Hurricane Katrina, 2006).  Predicting the number of people will evacuate is challenging.  Hurricane Pam simulations used figures based on only 36% of people within the 13-parish area would evacuate (Beriwal, 2006).  Having less people evacuate prior to Hurricane Pam making landfall exposes them to extreme threats including elevated water, loss of power, limited services, loss of communications, and inability to respond to those in danger.

The Southwest Louisiana Catastrophic Hurricane Planning Project unfolded in March, 2004, with a target of having a draft plan for July, 2004 (Fairley, 2006).  The first workshop was conducted in July when participants were introduced to Hurricane Pam disaster scenario and were divided into breakout groups by responsibilities (Fairley, 2006).  Leadership from FEMA Region 6 and Louisiana Office of Homeland Security and Emergency Preparedness (LOHSEP) created groups to address hurricane pre-landfall issues, search and rescue, temporary medical care, sheltering, temporary housing, schools, and debris (Fairley, 2006).  As the initial workshop unfolded, members identified additional key components that needed attention.  Access control and reentry, billeting of federal response workers, distribution of ice, water and power, donations management, external affairs, hazardous materials, transition from rescue to temporary housing, and unwatering of levee enclosed areas were added to the growing list of items that required additional attention following the initial workshop (Fairley, 2006).  The expansion in focus areas proved that additional workshops would need to occur to ensure to address the full range of complex issues related to a catastrophic event.

A second workshop occurred in November, 2004, that focused on sheltering, temporary housing, and temporary medical care (Fairley, 2006).  The third workshop occurred in July, 2005, and addressed transportation, staging, and distribution of critical resources and temporary housing (Fairley, 2006).  The forth workshop was conducted in August, 2005, and provided additional efforts on temporary medical care.

Many of the focus areas were addressed in multiple workshops demonstrating the challenges on response and recovery from such a damaging hurricane.  Medical care was a topic that appeared in the first, second, and forth workshops.  This is the only focus area that made three workshops, and creating its own as the only topic in August, 2005.  A FEMA press release (2004) after the initial workshop states, “The medical care group reviewed and enhanced existing plans. The medical action plan includes patient movement details and identifies probably locations, such as state university campuses, where individuals would receive care and then be transported to hospitals, special needs shelters or regular shelters as necessary” (Federal Emergency Management Agency, 2004).  The collaborative effort included multiple stakeholders represented by federal, state, local, and hospital organizations helps leverage resources and aligns efforts with a common understanding of how to provide medical services during a catastrophic disaster.

A draft version of the Southeast Louisiana Catastrophic Hurricane Plan was distributed to the state and localities in January, 2005.  The plan was rushed to allow stakeholders time to create additional detailed plans using the newly created content.  The plan included 15 subjects that emergency managers should address during and after a catastrophic storm impact their specific areas (Select Bipartisan Committee to Investigate the Preparation for and Response to Hurricane Katrina, 2006).  The additional action plans suggested in the Southeast Louisiana Catastrophic Hurricane Plan requires stakeholders to take the identified areas and build upon the basic plan. Basically, this was the starting point with the expectation that additional work would be done ahead of the upcoming hurricane season.

The Southeast Louisiana Catastrophic Hurricane Plan increased hospital emergency planning in many ways.  First, it brought together health and medical professionals from federal, state, and local levels to coordinate and develop plans to address an extremely complex demand from a devastating hurricane.  This was critical since a catastrophic disaster demands coordination form multiple partners from a variety of levels of government.  Second, the scenario used for Hurricane Pam was very similar to Hurricane Katrina (Beriwal, 2006).  The only major difference between the two storms was the percentage of people that evacuated (Beriwal, 2006). Hurricane Pam simulated that 36% of people would evacuated prior to landfall where 80-90% evacuated from Hurricane Katrina (Beriwal, 2006).  The evacuation figure correlates to the difference in deaths that were projected for Hurricane Pam, over 60,000, with Hurricane Katrina, 1,100 (Beriwal, 2006).  The rainfall, projected depth of flood waters, loss of power, buildings and homes destroyed, and all the way down to the number of chemical plants and oil refineries were very similar (Beriwal, 2006).  The ability to form a plan and conduct an exercise with emergency management partners for a scenario that mirrors a future catastrophic disaster is invaluable.

It can be concluded that the three medical specific workshops improved the dialogue and planning at the federal, state, and local level to discuss for the response and recovery for medical treatment during a catastrophic event like Hurricane Katrina.  Without the planning and involvement of Hurricane Pam, the health and medical systems could have performed at a lower functionality than during Hurricane Katrina.

Memorial Medical Center sits in the bustling Uptown neighborhood of New Orleans. The hospital was built in 1926 and situated in a low point three miles southwest of the city’s French Quarter (Fink, 2009). Memorial Medical Center accounts for 317 acute care beds to the New Orleans hospital network. An additional 82 beds belonged to LifeCare, an individually operated and licensed care provider who leased the seventh floor of the hospital (Fink, 2009). LifeCare cared for critically ill and injured patients in a 24-hour care and intensive therapy for long periods of time (Fink, 2009). The doctors and nurses operated independently from Memorial Memorial Medical Center and acted as a “hospital within a hospital” (Fink, 2009). The complexity of the internal structure for Memorial Medical Center requires additional considerations dealing with an external provider.

Memorial Medical Center had completed many emergency preparedness actions prior to Hurricane Sandy. First, Memorial Medical Center had a 246-page emergency plan that addressed a comprehensive list of disaster and emergency situations (Fink, 2009).  Second, Memorial Medical Center had established an emergency preparedness committee, led by Susan Mulderick, a nursing director, to coordinate emergency preparedness activities for the hospital (Fink, 2009). This is important because it demonstrates that an existing effort was made to bring together departments within Memorial Medical Center to develop an emergency plan.

It is not clear if Memorial Medical Center participated in the Hurricane Pam exercise or workshops.  The initial workshop was attended by emergency officials from 50 parish, state, federal and volunteer organizations (Federal Emergency Management Agency, 2004).  A participation roster was not found.  However, the development of an extensive emergency plan and existence of an emergency preparedness committee demonstrates that preparing for emergencies was current when Hurricane Katrina stuck in August, 2005.

St. Charles Parish Hospital is located in Luling, Louisiana, twenty miles west of New Orleans (Gray & Hebert, 2007, May).  The single-story hospital started operations in 1959 and serviced St. Charles Parish (Gensure & Adharsh, 2011).  The hospital provides 59 acute care beds and is accredited by the Joint Commission on Accreditation of healthcare Organizations (Ochsner Health System, 2017).  St. Charles Parish Hospital serves a community of 60,000 people (Gray & Hebert, 2007, May).  The hospital is located just seven blocks from the Mississippi River, but is above sea-level.  The location of St. Charles Parish Hospital has left if vulnerable to flooding, but has not previously evacuated (Gray & Hebert, 2007, May).  A major concern for the hospital is the fact that it is a single story structure.  Flooding would leave the hospital with no alternatives for operating within the structure on higher floors.

There was no known information available that document emergency preparedness activities for St. Charles Parish Hospital.  In the absence of available information, there can be multiple assumptions that can be drawn from two main points.  First, the hospital is accredited by the Joint Commission on Accreditation of healthcare Organizations.  Emergency preparedness standards are included in the accreditation process.  Hospitals are required to meet standards related to developing an emergency plan, continuation of care for patients, and developing procedures for conducting an emergency evacuation (The Joint Commission, 2016).  Since St. Charles Parish Hospital was accredited in 2005, an assumption can be made that emergency plans existed related to emergency management.  Secondly, the hospital conducted an evacuation prior to Hurricane Sandy making landfall and coordinated with the St. Charles Parish Emergency Operation Center and State Department of Emergency Medical Services (Gray & Hebert, 2007, May).  Understanding who to contact for requesting emergency support does not happen by accident.  These actions provide additional support that verifies the level of preparedness activities that were taken prior to Hurricane Katrina.

Hurricane Katrina

Hurricane Katrina formed from a tropical wave interacting with the fragments of a tropical depression that loss stability (Hurricane Science, n.d.).  On August 23, 2005, the storm became Tropical Depression Twelve causing the National Weather Services to issue its first advisory.  Tropical Depression Twelve was over the Bahamas located 350 miles east of Miami (Drye, 2005).  The storm continued to advance towards southern Florida.

On August 24, Tropical Depression Twelve become more organized, gaining strength, and now becomes the eleventh named storm, Tropical Storm Katrina. Katrina remained over the Bahamas while continuing a path westward towards Florida.  The strength of the storm developed as the strongest winds are blew at about 40 miles an hour (Drye, 2005).  Even while over land, Katrina showed signs of intensifying as it focuses on the warm water on its projected path.

Katrina continued to strengthen as it approached North Miami Beach on August 25.  The increased intensification and development had increased winds to 75 miles an hour, causing it to be designated as a Category One hurricane (Drye, 2005).  At 7:00 p.m., the eye of Hurricane Katrina made landfall between North Miami Beach and Hallandale Beach on Florida’s southeastern coast (Drye, 2005).  The eye of Katrina became more defined and remained intact while surging across Florida progressing towards the Gulf of Mexico.

After passing over Florida, the projected path of Katrina started to draw concern as it entered the warm waters of the Gulf of Mexico.  On August 26, at 1:00 a.m., Katrina weakened by crossing over Florida and is reclassified as a tropical storm (Drye, 2005).  However, immediately upon entering the Gulf of Mexico, Katrina started to quickly strengthen (Drye, 2005).  The very low shear environment over warm water caused the rapid intensification with winds reaching 75 miles per hour, now classified as a Hurricane One, after two short hours of reaching the Gulf of Mexico (Hurricane Science, n.d.).  The quick development of Hurricane Katrina caused The National Hurricane Center to warn that the storm is “rapidly strengthening” while it advanced over warm waters and warned the Gulf Coast states (Drye, 2005).  Governors Kathleen Blanco of Louisiana and Haley Barbour of Mississippi each declared states of emergency during the day due to the increased threat.  Projections late into the evening by The National Hurricane Center predicted that Katrina will become a “major hurricane” as it closed in on the Gulf States (Drye, 2005).  At 11:00 p.m., the eye of the storm was only 460 miles southeast from Louisiana and closing in quickly (Drye, 2005).  As the storm closed in to the shoreline, the path became clear that landfall would occur in either Louisiana or Mississippi.

Over the next couple of days, Katrina continued to expand is size and strength with winds reaching 115 miles per hour (Drye, 2005).  The radical intensification caused the storm to nearly double in size while producing hurricane force winds extending out 160 miles from the eye of the storm (Hurricane Science).  The rapid growth revealed the extreme threat it could cause for communities while leaving little time before it made landfall.

On August 28, at 2:00 a.m., Hurricane Katrina reached Category Four storm with winds up to 145 miles per hour while only 310 miles from land (Drye, 2005).  Understanding that seriousness of Katrina and the damage that it could pose, Mayor Ray Nagin issued the first ever mandatory evacuation of New Orleans at 9:30 a.m. (Kent, 2006).  Tens of thousands of New Orleans residents begin to leave their homes and escape the flood prone city (Drye, 2005). Louisiana State Police redirect the direction of traffic on Interstate 10 to only west and southern lanes of Interstates 55 and 59 to additional northbound lanes (Kent, 2006).  The mass evacuation continues as Katrina remains offshore and still gaining strength.

By 11:00 a.m., Hurricane Katrina produced winds blowing at a staggering 175 miles per hour, making it a Category Five hurricane (Drye, 2005).  The high winds and large amount of rainfall caused The National Hurricane Center stating that Katrina could cause “some levees in the greater New Orleans are could be overtopped” and that “significant storm surge flooding will occur elsewhere along the central and northeastern Gulf of Mexico coast” (Drye, 2005). Evacuations continued throughout the evening with approximately 1 million people adhering to Mayor Nagins’ order (Kent, 2006).  However, not all residents have been evacuated.  Many of those that remained did not have the means to evacuation or a place to go.  Despite the success of increasing evacuation travel lanes in safe directions, approximately 150,000 people, mostly poor and disables, were unable to evacuate (Kent, 2006).  Some would leave before landfall, but many stranded and remained in their homes or in other shelters.

On August 29, Hurricane Katrina made its final approach towards Louisiana, but began to weaken slightly with winds measuring 155 miles per hour (Drye, 2005).  At 2:00 a.m., the storm was only 130 miles from New Orleans and moving north.  The rainfall was quickly causing concerns for New Orleans, a city that sits at or below sea level, while they waited for the eye of Katrina to make landfall.

At 8:00 a.m., Mayor Ray Nagin received reports that water is flowing over one of the New Orleans’s levees (Drye, 2005).  New Orleans is surrounded by a complex levee system that protects its population from the dangerous water that surrounds the city.  However, the levee system has limits. Katrina was extremely large and powerful, producing 10-12 inches of rain and 15 feet of storm surge (Kent, 2006).  A failure of a levee at one point in the system could cause cascading impacts on other parts of the system.

Hurricane Katrina’s eye made landfall near the Louisiana-Mississippi board at 11:00 a.m. (Drye, 2005).  Rainfall continued to fall at a staggering pace and created additional pressure on the fragile levee system.  Additional breaks were reported throughout the remainder of the day and into the next as Katrina moved over Tennessee, pouring rain along its path. Katrina was now a Tropical Depression as it continued in a northeastern direction up to Ohio.  The storm had come and gone for New Orleans, but the damage was done. New Orleans now faces the after-effects of on of the most damaging hurricane in history.

Memorial Medical Center

Memorial Medical Center did not evacuate prior to Hurricane Katrina.  It is important to take the information about Katrina and compare it to the actions taken by Memorial Medical Center.  Examining the known information in a subjective manner is easy after an event has occur.  The intention of this study is to analyze the actions that occurred during the event as it unfolded and compare the alternative decision on evacuation made by a second sample.

New Orleans is prone to hurricanes. Previous interactions and experiences mold assumptions for future events (Gray & Hebert, 2007, May).  Staff at Memorial Medical Center often brought their families into the hospital to take shelter from threatening storms (Okie, 2008). Doctors, nurses, and support staff were expected to work long hours and having family at the hospitals allowed reassurance that they were safe from the unknown at their homes.  The leniency to allow family and pets to cohabitate with medical professionals allowed them to remain focus on continuing care for patients for long durations.  However, the downside to adding the population census inside the hospital can cause strain on finite resources during emergencies.  When Katrina was approaching, about 2,000 people were inside Memorial Medical Center, including more than 200 patients and 600 workers (Fink, 2009).  Not understanding the potential threat, many residents left their homes to seek shelter inside the hospital.  Over half of the people within Memorial Medical Center were either family members of patients or residents of the community trying to increase their chances of surviving from the wrath of Katrina.

On Sunday, August 28, Mayor Nagin issues a mandatory evacuation for New Orleans. Hurricane Katrina showed signs of strengthening and the ability to produce high winds, extensive amount of rain, and storm surge that could cause flooding to all of New Orleans (Drye, Hurricane Katrina: The Essential Time Line, 2005).  The projected flooding could cause the hospital to become isolated and without power.

On Monday, August 29, Hurricane Katrina made landfall and many of the levees across New Orleans started to fail and water was pouring into the city (Drye, A Timeline of Hurricane Sandy’s Path of Destruction, 2012).  The commercial power to the hospital was lost at 4:55 a.m. (Fink, 2009).  Emergency generators quickly turned on providing the essential power needed to continue caring for patients.  The emergency generators were designed to power emergency lights and limited power to specific areas of the hospital (Fink, 2009).  Emergency generators are not meant to replace the same power output that is commercially available and used during normal conditions.  The air condition system is not an essential service and shut off when commercial power was lost (Fink, 2009).  The temperature within the hospital quickly increased and soon reached exhausting temperatures near 100 degrees (Fink, 2009).  The increase in temperature contributes to the level of discomfort felt by patients and staff.

Reports of flooding and levee failures reached hospital leadership and resulted in a meeting on Tuesday, August 30 (Fink, 2009).  The emergency-power switch for the hospital was located below ground level putting in jeopardy the emergency power currently operating the hospital (Fink, 2009).  Many staff voiced concern about operating on emergency generation and advocated for the immediate evacuation of patients and occupants of Memorial Medical Center (Fink, 2009).  The risk of losing all power was too great.  Memorial Medical Center would need to evacuate more than 180 patients, family members, and staff (Fink, 2009).  Time was ticking and the evacuation plan had to be implemented before resources become exhausted and emergency generators quit working.

The evacuation process would be led by Susan Mulderick, a 54-year-old nursing director and contributor to the hospital emergency plan (Fink, 2009).  Memorial administration staff reached out to their hospital ownership, Tenant Corporation, based in Dallas, Texas, asking for assistance and communicated their intention to evacuate the hospital (Fink, 2009). Communication between the hospital and corporate leadership was limited due to the damage occurring in New Orleans.  This would be one of the only messages that Dallas would receive about the difficulties that Memorial Medical Center was facing in the aftermath of Katrina.

The process to be used to evacuate became the point of contention.  Patients included those from the intensive care unit, premature infants, critically ill patients that required dialysis, patient’s dependent of durable medical equipment, patients with do-not-resuscitate (DNR) orders, and obese patients (Priest & Bahl, 2008).  Doctors quickly decided that babies in neonatal intensive-care unit, pregnant mothers, and adults in the intensive care unit faced the greatest risk from the souring temperatures and should be prioritized as the first to be evacuated (Fink, 2009). The evocation plan now had to be implemented.

Evacuation occurred by helicopter using the helipad on top of the eight story adjacent parking garage.  Staff quickly cleared the unused pad to prepare for landing of Coast Guard and private ambulance company helicopters to expedite evacuation (Fink, 2009).  The first two helicopters that arrived intended to deliver patients to the hospital, not evacuate existing patients (Gray & Hebert, 2007, May).  Throughout the afternoon and early evening hours, the hospital was able to evacuate roughly 57 patients, reducing the census from 187 to 130 (Fink, 2009). Hospital leadership decided to cease evacuation operations during the evening and overnight because of the lack of lighting on the temporary helipad (Fink, 2009).  Staff would have to continue care while developing evacuation plans for the following day throughout the night.

At 2:00 a.m. on Wednesday, August 31, the backup generators sputtered and stopped (Fink, 2009).  Equipment would now operate on battery power until they were drained.  Staff quickly began to take care of patients manually, replacing machines once they ceased to operate. Basic amenities were unavailable and water had stopped flowing from taps (Fink, 2009). Without electricity the whole plumbing systems could not operate creating an extremely hazardous environment.  Patients continued to be evacuated by helicopter in the early morning hours (Fink, 2009).  Patients that were on ventilators were prioritized to help reduce the staff needed to manually pump airbags to keep patients alive.

The change in hospital conditions forced staff to create alternative means to expedite the evacuation process.  That morning, several boats arrived to the loading docks looking to provide help (Fink, 2009).  Patients were transported by boat to higher-ground and handed off to ambulances to deliver patients to alternate care facilities (Priest & Bahl, 2008).  Staff quickly categorized patients into three groups.  Patients marked as “1’s” were in fairly good health and could walk or sit up and were prioritized for being the first evacuated (Fink, 2009).  Patients marked as “2’s” required additional assistance and would be the group that followed the full evacuation of those patients marked in the previous group (Fink, 2009).  The remaining patients, those requiring additional medical support were marked “3’s” and would be the last to evacuate (Fink, 2009).  The group designations were marked directly on the patients clothing or on paper and taped to patients.

Patients in the first group were taken to the emergency room loading dock where boats were arriving (Fink, 2009).  The second group of patients were placed in the corridor that led to the helipad for quicker loading when additional helicopters arrived.  The final group, the patients requiring the most medical assistance, were moved in a corner of the second floor lobby that was isolated from any hope of immediate departure (Fink, 2009).  On Wednesday evening, while 115 patients still awaited evacuation, the boats suddenly stopped and patients were brought back inside to remain for another night (Gray & Hebert, 2007, May).  The remaining patients and staff would have to survive another dreadful night before being evacuated.

The morning of Thursday, September 1, brought fishing vessels, small personal boats, and helicopters to continue evacuation operations (Fink, 2009).  As more patients continued to evacuate, the patients left were those in the direst conditions.  Finally, six helicopters that were chartered by Tenet arrived and the remaining patients were evacuated (Gray & Hebert, 2007, May).  The evacuation was complete and all surviving patients were transported to alternate care centers.

The experience at Memorial Medical Center was horrific.  A total of 45 bodies were found on September 11, 2005, 13 days after Katrina hit New Orleans (Fink, 2009).  The health of patients was tested by the loss of power, sweltering temperatures, and unsanitary conditions.  The damage to Memorial Medical Center was extensive and repairing the facility would take time.  Additionally, many of the residents of New Orleans left after Katrina and would not return; abandoning what was left of their homes and possession (Coombs, 2015).  The demand for hospitals was not needed.

Ochsner Health System purchased Memorial Medical Center from Tenant in 2006.  The new hospital, Ochsner Baptist Medical Center, would receive over $100 million in renovations (Coombs, 2015).  A major component of the investment went into ensuring that the hospital never would experience the horrific conditions that were brought after Hurricane Katrina.  An elevated emergency generator was purchased to power the entire hospital, a fleet of boats, and water and fuel lines reinforced to ensure that operations continue to function when faced with dangerous levels of flooding and other emergencies (Coombs, 2015).  Making improvements to structure components and increasing internal response capabilities enforces a comprehensive approach to emergency preparedness.  Ochsner Baptist Medical Center has taken action to mitigate a disruption for future disasters.

Saint Charles Parish Hospital

Saint Charles Parish Hospital sits in rural Luling, Louisiana, twenty miles west of New Orleans, serves a community of nearly 60,000 residents (Ochsner Health System, 2017).  The single story hospital is located in the downtown section of Luling only blocks away from the Mississippi River.  Saint Charles Parish Hospital opened in 1959 and is accredited by the Joint Commission on Accreditation of healthcare Organizations (Ochsner Health System, 2017).  The hospital had never had previous flooding concerns or conducted an evacuation.  However, Hurricane Katrina was not a normal hurricane.

On Saturday, August 27, as Hurricane Katrina sat nearly 400 miles from the coast of Louisiana with winds reaching 115 miles per hours, hospitals officials at Saint Charles Parish Hospital began to consider conducting an advance evacuation (Gray & Hebert, 2007, May). Louisiana Governor Kathleen Blanco declared a state emergency the day prior in anticipation of the increasing threat from Katrina (Drye, Hurricane Katrina: The Essential Time Line, 2005). Additionally, Saint Charles Parish issued a mandatory evacuation order effective at noon on Saturday, roughly 42 hours before expected landfall (Wu, Lindell, & Prater, 2012).  The evacuation order help gives Saint Charles Parish Hospital leadership a justification for conducting the first evacuation in the hospitals history.

Starting Saturday afternoon and into the evening, the chief executive officer called several hospitals to find alternate care cites for their patients (Gray & Hebert, 2007, May). Desoto Hospital in Mansfield, Louisiana, nearly 300 miles away, agreed to accept the patients from Saint Charles Parish Hospital.  Throughout the evening and into the night, hospital leadership started to develop a strategy to execute the evacuation.

On Sunday morning, August 28, the plan was presented to key leadership and the decision was made to conduct the evacuation.  The evacuation plan was to use three ambulances for the six patients that needed additional medical care, two wheelchair accessible school buses that had been outfitted for parish residents that needed medical attention, and two additional buses that would transport the psychiatric patients (Gray & Hebert, 2007, May).  The buses were to leave at 1:00 p.m. and followed by the ambulances at 4:00 p.m.  The plan was sound and well-coordinated, however New Orleans Mayor Nagin ordered a mandatory evacuation earlier that morning at 9:30 a.m.  The evacuation of Saint Charles Parish Hospital would soon collide with the rush of evacuees from New Orleans.

During the first leg of the planned route, the buses entered congestion and was barely moving.  A routine one-hour trip took the buses 6-7 hours (Gray & Hebert, 2007, May).  The buses continued to move forward on the route until 10:00 p.m. when they reached Lafayette.  The buses traveled 120 miles in 9 hours (Gray & Hebert, 2007, May).  Recognizing the remaining trip would take another full day of driving in a very congested roadway, the decision was made to coordinate with local hospitals in Lafayette to accept the patients and the remaining would ride out the storm in a shelter until Katrina had passed (Gray & Hebert, 2007, May). Coordination to find an appropriate shelter was led by the Saint Charles Parish Emergency Operation Center and the State Department of Emergency Medical Services (Gray & Hebert, 2007, May).  Once the conditions lifted, the buses continued to Mansfield as planned.

The six patients being transported by three ambulances arrived at Desoto Hospital in Mansfield by 10:00 p.m. (Gray & Hebert, 2007, May).  The trip was slow, but a police escort for portions of the route allowed for quicker travel in gridlock traffic.  The patients were admitted and remained in care in Mansfield for the duration of the week (Gray & Hebert, 2007, May). Saint Charles Parish had successfully evacuated all their patients to alternate care sites during a very challenge transportation environment.

Saint Charles Parish was impacted by Hurricane Katrina and Saint Charles Parish Hospital lost commercial power (Gray & Hebert, 2007, May).  The hospital emergency room and ancillary clinical departments opened late on Monday while operating on emergency generator power (Gray & Hebert, 2007, May).  However, no patients were admitted for care until commercial power was restored later in the week.  Patients that had been evacuated arrived back to Saint Charles Parish Hospital when power was restored and became fully operational (Gray & Hebert, 2007, May).  Additionally, the hospital ended up serving stranded individuals who were restricted access to Jefferson and Orleans Parish.  The hospital quickly setup an outpatient triage center serving around 1,000 patients each day (Gensure & Adharsh, 2011).  The actions taken by St. Charles Parish Hospital allowed for a quick recovery and ability to handle the additional surge of patients during a difficult environment.

Katrina Comparative Analysis

Conducting an evacuation of a hospital is considered to be the last resort (Childers, Mayorga, & Taaffee, 2014).  Evacuations can expose patients to dangerous external conditions that result in unintended consequences that exacerbate the patients’ health (Bjarnadottir, Li, & Stewart, 2011).  The decision to implement evacuation is challenging.  The process requires assessing the situation and predictions, understanding capabilities, and identifying vulnerabilities.

Hurricane Katrina impacted both Memorial Medical Center and Saint Charles Parish Hospital.  The strong Category 3 Hurricane brought massive rainfall, devastating winds, and intense storm surge across Louisiana (Drye, Hurricane Katrina: The Essential Time Line, 2005). Memorial Medical Center decided to shelter-in-place while Saint Charles Parish decided to evacuate prior to landfall.  Hospitals are essentially designed to continue operations while sheltering in place (Rodriguez & Aguirre, 2006, Fall).  However, not every hospital can evacuate when threatened by a hurricane.  An assessment is required to identify the correct actions needed to ensure the safety and care of patients and staff.

A comparative analysis is the item-by-item comparison of two or more comparable alternatives, processes, products, qualifications, sets of data, systems, or the like (Business Dictionary, 2017).  The constant in the analysis is the hurricane and the alternatives is the decision made by each hospital.  The item-by-item comparison will include vulnerabilities to utilities and communications, resources, external factors, patient care, and recovery time.

Utilities

The first items covered in the comparative analysis in the vulnerability on utilities.  It is essential to conduct an assessment for vulnerabilities for power and water systems.  Memorial Medical Center had emergency generators that had the ability of providing essential services during loss of commercial power.  The major vulnerability to the system was the location of the transfer switches that were only a couple of feet above ground (Fink, 2009).  The transfer switch, a necessity to operate the emergency generator, was extremely vulnerable to floods.  The loss of the power switch had cascading impacts on other vital systems.  Without power the water system pumps become inoperable causing water to stop flowing from taps, toilets to back up, and loss of being able to shower patients and staff (Fink, 2009).  The loss of power and water made the task of treating patients extensively more challenging.

Saint Charles Parish Hospital assessed Hurricane Katrina differently.  Hospital leadership looked at the hurricane as being a major threat to the area.  The single story hospital could flood and lose power.  After analyzing the forecast and identifying vulnerabilities an evacuation plan was drafted and implemented within 24 hours (Gray & Hebert, 2007, May).  The hospital layout, being one level, leaves little alternative planning when facing the threat of floods.

Communications

Communications are essential during emergencies to interact with stakeholders in preparedness, response and recovery of hospital operations.  External communications are used to speak with state and local agencies, other health providers, and local government.  The use of emails and cell phone is the primary means of communicating with external partners.  Internal communications, used within the hospital includes landline phones, pagers, email, and intercom system, are essential to coordinate hospital operations.

There were many examples at Memorial Medical Center demonstrating the lack of ability to communicate with external partners.  Tenant Corporation in Dallas had started coordinating private transportation assets to help in the evacuation process on Wednesday, August 31.  Tenant was unable to communicate their plans to hospital leadership due to communication challenges when the hospital was operating without power (Fink, 2009).  It was not until a day later that the chief financial officer, Curtis Dosch, was able to reach Tenant in Dallas to receive the message about the incoming helicopter assistance (Fink, 2009).  A second example of communications challenges existed when the first helicopter landed on top of the adjacent parking garage intending to deliver patients instead of evacuating patients (Gray & Hebert, 2007, May).  The inability to communicate with the city emergency operation center or state level coordination centers created situations that hindered the evacuation.

Saint Charles Parish conducted the hospital evacuation when communications systems were operational. Evacuation planning occurred three days prior to Hurricane Katrina making landfall (Gray & Hebert, 2007, May).  Conducting essential evacuation communications with alternate care centers and resource providers ensured that plans were developed and shared with stakeholders prior to any potential disruption.  A second example of successfully communications occurred on the day of the evacuation.  Hospital leadership was able to coordinate with the St. Charles Parish Emergency Operation Center and State Department of Emergency Medical Services to divert the buses to a shelter due to congested roadways (Gray & Hebert, 2007, May).  This effort allowed for patients to continue receiving care in an appropriate setting.  The buses were stranded and the communications between state and local government agencies were essential to creating a solution to a challenging situation.

Resources

Resources within a hospital provide equipment and supplies needed to care for patients. Hurricanes can create challenges for obtaining resources during an emergency.  Flooding can create roadblocks making a hospital inaccessible for needed resources.  The lack of resources during an emergency could result in patients not receiving the care they need and could cause casualties.  If multiple hospitals decide to shelter-in-place during a hurricane and later forced to evacuate they could be competing for the finite resources causing a more complex and urgent situation (Gray & Hebert, 2007, May).  Resource management and planning needs to occur in preparation of any known event to ensure essential materials are available if the hospital becomes isolated and needs to be self-sufficient.

Memorial Medical Center did not have adequate resources on hand to provide to care for the approximately 2,000 patients, family, staff, and residents that took refuge inside the hospital (Fink, 2009).  The impact from Hurricane Katrina strained the ability to use existing resource which led to exacerbating secondary resources.  As an example, oxygen is supplied through a large system that distributes supply patient areas throughout the hospital.  The quantity of reserve oxygen tanks may be sufficient when the system is large system is working.  Without power and the emergency generator working, the demand for the same number of oxygen tanks becomes stressed.  The cascading impacts from vulnerability can cause damaging consequences into other essential.  Priest and Bahl (2008) state that catastrophic disasters are characterized, in part, by limited resources (Priest & Bahl, 2008).  Resource shortfalls can quickly impact the ability to provide care for patients.

Saint Charles Parish Hospital had a different experience.  Staff packed a weeks’ worth of medicine for each patient into bags that accompanied them to the alternate care facility (Gray & Hebert, 2007, May).  The only resource constraint that Saint Charles Parish Hospital experienced was finding ambulances that could transport patients such a long distance.  The difficulty in arranging ambulance transportation caused a three-hour delay in departure from the hospital (Gray & Hebert, 2007, May).  The ability to communicate with the provider allowed for the issue to be corrected.  Additionally, the coordination between partners during the evacuation allowed for the ambulances to receive a police escort for parts of the route (Gray & Hebert, 2007, May). This allowed for patients to be transported expeditiously during gridlock on highways exiting the coastal area of Louisiana.

External Factors

There are many external factors that play into the decision to evacuate a hospital.  State and local leaders often provide guidance and issue evacuation orders.  Modifications to orders can exempt hospitals since they provide essential services to residents.  Direction can be initiated beyond the hospital administration and be given by corporation leadership or those above the chain of command.  There are many stakeholders at various levels that have the ability to provide guidance and direction related to hospital operations and possible evacuations.

Mayor Ray Nagin issued a mandatory evacuation order for residents of New Orleans the morning of August 28 (Drye, Hurricane Katrina: The Essential Time Line, 2005).  The order came a day after Governor Kathleen Blanco ordered a state of emergency (Drye, Hurricane Katrina: The Essential Time Line, 2005).  Tenant Corporation never forced the issue for Memorial Medical Center to evacuate the hospital.  The timing of the evacuation may have been too late when Mayor Nagin ordered evacuation for New Orleans, but there was no indication that any plan was even discussed.

The outside influence for Saint Charles Hospital was similar to Memorial Medical Center.  Saint Charles Parish leadership ordered a mandatory evacuation, but there was no enforcement from law enforcement (Gensure & Adharsh, 2011).  Most residents obeyed the order and businesses, schools, and other services shut ahead of the storm (Gensure & Adharsh, 2011).  Saint Charles Parish Hospital was not forced by leadership to conduct an evacuation, but decided that losing power and possible flooding of single story hospital was not a risk leadership were willing to take.  The internal assessment of risk and existing vulnerabilities drove the decision to conduct the evacuation when the environment was safe.

Patient Care

Deciding to either evacuate or shelter-in-place for a hurricane focuses on the continue care of patients.  The decision to evacuate a hospital to protect against the potential risk from a hurricane must be balanced against the inherent risks of the evacuation itself to vulnerable populations (New York City, 2013).  The act of evacuating hospital patients can make existing conditions worse and increase mortality rates among those evacuated (New York City, 2013). Alternatively, caring for patients without power, water, and appropriate medical equipment is neglectful and could exacerbate medical conditions and increase mortality rates.  It is a difficult decision and requires careful analysis of vulnerabilities and capabilities to ensure the result is the best care for patients.

Memorial Medical Center faced many challenges when providing care for patients after Hurricane Katrina made landfall.  The hospital operated without power and running water while dealing with temperatures inside above 100 degrees (Fink, 2009).  Nurses and doctors performed additional task that are routinely done by machines.  The conditions were dire and help was slow to arrive.  Against unfavorable odds, the hospital staff performed to the best of their abilities throughout the grueling evacuation process.  For over three days, staff worked in the conditions with with each passing hour worse than the one before.  The evacuation resulted in nearly 200 patients reaching alternate care facilities, but 45 patients died at Memorial (Fink, 2009).  Their conditions could not tolerate the extreme environment and they did not receive the care they needed.

Saint Charles Parish Hospital evacuated a day prior Hurricane Katrina making landfall. The well-coordinated evacuation ensured that patients were transported using appropriate medical vehicles, medication for each patient, and appropriate staff accompanying the transport to the alternate care site (Gray & Hebert, 2007, May).  Initial evacuation plans were changed during the process due to external factors, but solutions were quickly implemented focused on providing the best patient care.  All patients successful reached an alternate care site without any fatalities (Gray & Hebert, 2007, May).  The planning, communication with internal and external partners, and quick thinking of leadership contributed to the success to the evacuation and patient care.

Recovery Time

Hospitals provide an enormously valuable service to their communities.  The ability for a hospital to remain operational to provide medical services is important.  When a hospital is closed and not able to provide services, the requirement for care does not go away, rather it is shifted to alternative care facilities.  The increase demand on hospitals that remain operational after a disaster can cause stress on staff and resources as they compensate for the decrease in providers.

Memorial Medical Center did not restore services for months after the evacuation. The hospital required extensive improvements and maintenance to regain operational status.  The New Orleans residents that returned to their homes would receive medical care at other locations. Memorial Medical Center would be purchased by Oschner Health System and reopen in phases as the hospital received the needed restorations.  Oschner Baptist Medical Center opened the newly remodeled emergency room on January 12, 2009 (Vargas, 2009).  Additional services have since been added.

Saint Charles Parish Hospital did not receive any damage as a result of Hurricane Katrina.  Hospital operations continued throughout the storm, but no patients were admitted because the hospital was operating on emergency power (Gray & Hebert, 2007, May).  Power was restored by the end of the week and the hospital resumed normal operations (Gray & Hebert, 2007, May).  There was minimal disruption in services due to the cautious actions of shutting down power and steam ahead of the storm.

Hospital Preparedness - Sandy

New York City is the largest city in the United States with over 8.2 million people in 2010 (United States Census Bureau, 2015).  The city has 62 acute-care hospitals throughout the five boroughs (Barnet, 2015).  The resource enriched metropolis is also not a stranger to emergencies and hurricanes.  New York City was the target of the largest terrorist attack on U.S. soil on September 11, 2001 when two planes flew into the World Trade Towers in lower Manhattan.  Since these attacks, New York City Police Department states that there has been 20 known plots against targets throughout the city (New York City Police Deparment, 2017). Heightened alert is second nature for New York City. Emergency planning efforts continue throughout the year to prepare for the unthinkable to ensure that medical care in the United States largest city meets the demand.

Hurricanes bring a barrage of detrimental impacts causing cascading issues that cause extensive damage.  The array of threats is not always the same.  A hurricane can be fast moving with strong winds, but produce minimal rainfall.  Other hurricanes may move slowly with minimal winds, but create long periods of heavy rainfall creating widespread flooding.  Each is troubling, but when a hurricane hits a heavily populated area with strong winds, extensive rain, and historic storm surge, the results are extremely damaging.

Hurricane Irene impacted the New York City area on August 28, 2011.  The impact from Irene brought to light that many parts on New York City were prone to potential damaging consequences from hurricanes.  New York City Emergency Management worked with stakeholder agencies at the local, state, and federal levels of government, non-profit and resident organizations on collaborative emergency planning for all emergencies to include hurricanes (Office of Emergency Management, n.d.).  New York City had dodged the direct impact from Hurricane Irene, but hospitals started to talk about what could have happened.  Hospitals reviewed their emergency plans and reassessed vulnerabilities (Uppal, et al., 2013, April). Bellevue Hospital and New York Downtown Hospital are two medical centers that took some preparedness actions during this time.

Bellevue Hospital received minimal impact from Hurricane Irene a year prior to Hurricane Sandy.  Hospital staff did however review emergency plans and prepared for potential impacts leading up to landfall (Uppal, et al., 2013, April).  A major concern from preparing for Hurricane Irene was the emergency power supply (Uppal, et al., 2013, April).  Generators were located on the 13th floor, well above any flooding concern, but the fuel pumps that fed the generators were located in the basement.  If flooding occurred and entered the basement the pumps could be submerged and cease to function.  The lack of commercial and generator power would cause damaging consequences that would endanger patients and staff.

To mitigate the problem, hospital leadership decided to encase the pumps within protective structures and seal the area with submarine-style doors (Uppal, et al., 2013, April). Sealing the pumps would provide a layer of protection to protect the pumps from water in case it breached the doors.  The doors installed were intended to keep a tight seal that blocks water from entering an enclosed area.

Bellevue Hospital hospital is accredited by the Joint Commission on Accreditation of healthcare Organizations  (Mbewe & Jones, 2013).  The accreditation requires hospitals to create a plan for emergency preparedness and conducted exercises twice a year (The Joint Commission, 2016).  Emergency plans are living documents.  They require constant review and updating to remain relevant to the changing environments.  Implementing portions of an emergency plan for real events allows for continuous assessment and provides lessons learned.  Bellevue had demonstrated they were prepared for a hurricane and had taken steps to mitigate the vulnerabilities identified one year prior to Hurricane Sandy.

New York Downtown Hospital took a different approach to enhance emergency planning before Hurricane Sandy.  The hospital focused their hurricane preparation by participating in exercises, coordinating with network providers that had experience evacuating, and attending collaborative meetings that addressed many issues and concerns like evacuations (Villacara, 2014).  New York Downtown hospital participated in a shelter-in-place study led by the New York City Department of Health and Mental Hygiene (Villacara, 2014).  The study assessed the ability for hospitals to continue care within hospitals verses evacuating (U.S. Department of Health and Human Services, 2013).  The study provided visibility to city and state agencies to understand potential shortfalls and gaps that may occur that disrupted services for hospitals.

The hospital also attended the System Emergency Management Forum meetings on a quarterly basis since 2009 (Villacara, 2014).  Forum meetings bring together stakeholders within a common industry to discuss current topics and share best practices.  Leveraging resources and addressing concerns with additional partners brings various viewpoints and ideas that could be vacant within current plans.

Learning from previous disasters allows for strengths and weaknesses to be addressed through a corrective action plan.  New York Downtown Hospital did not evacuate for Hurricane Irene, however they reached out to hospitals that had to learn from their experience.  Palisades Medical Center in North Bergen, New Jersey evacuated on August 26, 2011 as water was nearing the entrance to the hospital (Villacara, 2014).  The hospital shared the lessons they learned with New York Downtown Hospital.  Key points included evacuating prior to the storm making landfall, discharge approximately 30% of patients prior to evacuation, move the sickest patients first, and plan ahead for transportation resources since they will be limited closer to the storm (Villacara, 2014).  Understanding recommendations and lessons learned from actual events is invaluable.  New York Downtown Hospital did not have to experience the event that Palisades Medical Center did, but learned the same valuable lessons and incorporated changes to their existing emergency plans.

Hurricane Sandy

Late into the hurricane season, on October 11, 2012, a tropical wave formed off the coast of Africa (New York City, 2013).  The system gained momentum until it reached the southern Caribbean Sea off the coast of Nicaragua (Drye, A Timeline of Hurricane Sandy’s Path of Destruction, 2012).  The tropical depression strengthened and became the 18^th named storm of the 2012 hurricane season, Tropical Storm Sandy, on October 22 (New York City, 2013).

On October 24, Sandy moved north and crossed over Jamaica with winds of 80 miles per hour and dumped more than 20 inches of rain on Hispaniola (Drye, A Timeline of Hurricane Sandy’s Path of Destruction, 2012).  Sandy was now a Hurricane One and showed signs of strengthening with a more developed eye that could be seen by satellite imagery (New York City, 2013).  Sandy showed signs of continuing to develop while maintaining a track across the Caribbean Sea and moving north into the Atlantic.

Sandy reached Cuba as a Category 3 hurricane on October 25 (New York City, 2013). The damaging winds and torrential rains caused widespread damage to Santiago de Cuba and communities across the island (Drye, A Timeline of Hurricane Sandy’s Path of Destruction, 2012).  Sandy took a north-northwest turn towards the Bahamas, and onward to Florida’s east coast.

As Sandy crossed over the Bahamas it lost strength and became a Category 1 hurricane (Drye, A Timeline of Hurricane Sandy’s Path of Destruction, 2012).  Sandy lost wind strength, but increased substantially in size (New York City, 2013).  The waters in the Atlantic are warmer later in the Atlantic hurricane season allowing for storms to gain strength when moving further north along the east coast.  Its winds whirl counterclockwise, causing rising water levels all the way from Florida to Maine (New York City, 2013).  With the increased size and progressing structure, Sandy posed a serious threat with an unclear path.

On October 28, Sandy encountered two weather systems creating a shift in direction and rapidly intensify off the coast of South Carolina (New York City, 2013).  This unique conversion of weather systems with Hurricane Sandy caused meteorologist to warn the morphing could result in a powerful, hybrid super-storm as it churns northward (Drye, A Timeline of Hurricane Sandy’s Path of Destruction, 2012).  A high-pressure cold front forced Sandy to change course and run to the northwest aiming for Baltimore, Washington, Philadelphia, and New York (Drye, A Timeline of Hurricane Sandy’s Path of Destruction, 2012).  Encountering the weather systems helped Sandy increase in size with winds covering about 1,000 miles (Drye, A Timeline of Hurricane Sandy’s Path of Destruction, 2012).  Sandy may not have been a powerful hurricane, but the size and direction of the path causes great concern.  New York City Mayor Bloomberg issued a mandatory evacuation of Evacuation Zone A after hearing recent storm surge forecasts from the National Weather Service (New York City, 2013).  Parts of New York City were forecasted to receive storm surge of 11 to 12 feet (Drye, A Timeline of Hurricane Sandy’s Path of Destruction, 2012).  With the addition of a full moon and a unique “spring tide” caused storm surge projections to be even higher (New York City, 2013).  The lack of any geographic protection on the southern end of New York made it extremely vulnerable if Sandy continued on the same path.

On October 29, Sandy made an unexpected turn towards the northeast resulting in a direct hit for the New Jersey coast (Drye, A Timeline of Hurricane Sandy’s Path of Destruction, 2012).  At 8:00 p.m., Sandy made landfall near Atlantic City, New Jersey as a post-tropical nor’easter (Drye, A Timeline of Hurricane Sandy’s Path of Destruction, 2012).  Regardless of the classification of Sandy, the levels of rainfall from such a massive storm were destine to cause widespread damage.  That is exactly what Sandy did across New York, New Jersey, and Connecticut.

Bellevue Hospital

Bellevue Hospital was founded in 1736 and is the oldest public hospital in the United States (van de Leuv, 2013).  Bellevue is located less than 1,000 feet from the East River and sits 20 feet about sea level (Uppal, et al., 2013, April).  The 828-bed facility is the primary teaching hospital for New York University School of Medicine and serves some of the most vulnerable people of the largest city in the United States (Uppal, et al., 2013, April).  Bellevue is a level 1 trauma center that has 56 intensive care units, a locked tuberculosis isolation ward, and extensive outpatient clinic that serves thousands each day (Uppal, et al., 2013, April).  Bellevue Hospital is a high demand hospital that provides extensive services to a large population. An interruption in services could be detrimental.

Hurricane Sandy started causing concerns for the New York City metropolitan area on October 27, 2012, when it encountered two weather systems and started to drastically intensify while shifting in direction (Drye, A Timeline of Hurricane Sandy’s Path of Destruction, 2012). On October 28, Mayor Bloomberg ordered a mandatory evacuation for Evacuation Zone A, the most vulnerable areas to the forecasted storm surge (New York City, 2013).  Bellevue Hospital was not in Evacuation Zone A, and was not directed by the New York City Hospital Evacuation Center (HEC) to evacuate (New York City, 2013).  The city used the best available forecast data and instructed hospitals to begin discharging patients that could safely be discharged and to cancel elective surgeries (New York City, 2013).  The decision was made to shelter-in-place and prepare for possible impacts.

At 8:00 a.m. on October 29, nearly 12 hours before Sandy would make landfall, parts of Manhattan were already at flood stage at high-tide (Uppal, et al., 2013, April).  The water quickly decreased as the tide left, but following tides would worsen as Sandy moved towards New York City.  Throughout the day, staff arrived early with the understanding that transportation would be shut down and roads may become impassible (Mbewe & Jones, 2013). Departments within the hospital started organizing staff and the command center was operational (Uppal, et al., 2013, April).  Hospital staff conducted reevaluations of patients to ensure the most current status and diagnosis were documented incase an evacuation needed to occur (Uppal, et al., 2013, April).  Oxygen tanks were placed next to each patient for backup to the primary pumps located in the basement (Uppal, et al., 2013, April).  Efforts were made to ensure that the hospital would continue to care for patients to the best of their ability, regardless of what came next.

Into the evening hours, Sandy produced 70 miles per hour wind gusts that damaged a primary cell tower that created significant interruptions (Uppal, et al., 2013, April).  The loss of power remained the primary concern.  A committee met that included representatives from critical care, surgery, nursing, and ethics to review every patient in the ICU and evaluated their severity of illness, determined the need for life-sustaining equipment, and assessment on chances of recovery (Uppal, et al., 2013, April).  Understanding the patients’ needs prior to an emergency allows for staff to ensure that the appropriate care is rendered in a challenging event.

Bellevue Hospital lost commercial power at approximately 9:00 p.m. when millions of gallons of water rushed into the basement (Uppal, et al., 2013, April).  The emergency generators quickly turned on and care continued without hesitation.  Power was not the only disturbance caused by the rushing water.  The elevator pits filled with water causing all 32 elevators to become incapacitated (Ofri, 2012, December).  The situation in the hospital quickly became more complex. Staff continued care while others tried to figure out solutions.

The basement was filling with water and high tide was still hours away.  At 10:00 p.m., the encasement around the pump system failed and became inoperable.  The emergency generators were dependent on their current fuel level and would only last two hours.  Losing power was not an option that the hospital could take.  If the pumps could not deliver fuel to the generator, then it had to get there somehow.  Quick thinking resulted in hundreds of hospital staff and National Guard troops forming a chain up 13 flights of stairs to where the emergency generators were located (Uppal, et al., 2013, April).  This innovative effort would continue throughout the night resulting in enough fuel to last approximately 72 hours (Uppal, et al., 2013, April).  The continuation of emergency power was vital to ensuring that care of patients continued while the situation was being assessed.

With the power situation temporarily resolved, another issue came to fruition. External damage to cell phone towers and internal damage to communications systems in the basement had caused a communication blackout (Uppal, et al., 2013, April).  Cell phones, landline phones, and emails were all inoperable leaving a handful of two-way radios and use of runners as the only communications available to coordinate operations (Uppal, et al., 2013, April).  This became increasingly challenging since elevators were disabled requiring runners to take stairs to relay messages.

The water supply became extremely limited due to the loss of the pump system in the basement.  Within hours the hospital would lose the ability to wash hands, bathe, or flush toilets (Hartocollis & Bernstein, 2012).  Patients requiring dialysis could not be performed with appropriate water pressure (Uppal, et al., 2013, April).  The loss of water would directly impact the care to patients by creating unsanitary conditions and create challenges performing required medical procedures.

The impacts from the flooded basement did not stop at power, communication, water, and loss of elevators, but extended to the potential loss of wall oxygen.  National Guard troops that had helped refueled the emergency generators were reassigned to bring H-cylinders of oxygen, each weighing 180 pounds, from the main floor to other areas of the hospital (Uppal, et al., 2013, April).  With alternative plans in place for oxygen and emergency generators operating for the near future, staff continued to operate throughout the night to the best of their ability.

At daybreak, the situation outside the hospital improved.  Water had receded and the wind had died down allowing for an opportunity to reassess.  Conditions were deteriorating and the fuel in the emergency generator was running low.  Commercial power was unlikely to be restored for days so the decisions was made to evacuate the 725 patients (Hartocollis & Bernstein, 2012).  The evacuation process would be difficult, but with determined hospital staff and National Guard troops were up to the task.

The first patients to be evacuated were reliant on mechanical ventilators or required dialysis (Uppal, et al., 2013, April).  Patients were carried downstairs by any person willing to help. Without elevators, ever patients would be required to be carried down to the main floor to await transportation by ambulance to alternate care sites (Uppal, et al., 2013, April).  By midday on Wednesday, October 31, conditions continued to improve allowing more access to Bellevue for additional support to arrive.  An additional 300 National Guards troops had arrived to help in the evacuation with nearly an unlimited amount of ambulances (Uppal, et al., 2013, April).  The evacuation process would be accelerated with the abundance of resources now unhand resulting in up to 30 patients leaving per hour (Uppal, et al., 2013, April).  By 10:00 p.m., all patients from the ICU had been evacuated (Uppal, et al., 2013, April).  Throughout the night and into the morning, nearly all patients had been evacuated.  The only patients that remained were two that required use of an elevator and patients with tuberculosis (Uppal, et al., 2013, April).  Within the next 12 to 48 hours, these patients would evacuate to alternate facilities.

Bellevue Hospital became the third hospital in New York City to evacuate after Hurricane Sandy made landfall (Hartocollis & Bernstein, 2012).  The successful and expedient evacuation of 725 patients in detrimental conditions is attributed to the coordination that occurred a year prior for Hurricane Irene (Hartocollis & Bernstein, 2012).  Staff attribute the success to members receiving training and participated in preparedness activities (Ofri, 2012, December).  Learning during an emergency can create additional stressors and chaos to an already difficult environment and cause unintended consequences.

All patients were routed to appropriate care centers while Bellevue focused on recovering service.  It would take until February 2013 for Bellevue Hospital to become fully operational (Uppal, et al., 2013, April).  Improvements were made to ensure that many of the vulnerabilities were mitigated for future disasters.  Vital systems in the basement would me moved to alternate locations not susceptible to flooding.  Federal disaster aid help expedite projects to create a more resistant hospital to ensure operability under future disasters.

New York Downtown Hospital

New York Downtown Hospital sits in lower Manhattan near the Brooklyn Bridge.  The 180 bed hospital provides care for neonatal immediate care, maternity, intensive care, coronary, and routine medical or surgical patients (Villacara, 2014).  The hospital took an active role in enhancing emergency plans when threatened by Hurricane Irene a year prior to Hurricane Sandy.

New York Downtown Hospital was very proactive in making a decision to either evacuate patients or shelter-in-place.  On October 27, Hurricane Sandy began spinning in the Atlantic Ocean moving up the east coast (Drye, A Timeline of Hurricane Sandy’s Path of Destruction, 2012).  Forecasters predicted that Sandy would encounter two weather systems and result in a potentially dangerous system that could increase in size and intensity (Drye, A Timeline of Hurricane Sandy’s Path of Destruction, 2012).  However, there was still uncertainty on where Sandy would make landfall, but the storm was large enough that impacts to the New York City area was very likely.

On October 27, hospital leadership, with support from multiple agencies, decided to evacuate all patients prior to Hurricane Sandy making landfall (Villacara, 2014).  The hospital discharged approximately 26% of their patients prior to conducting evacuations (Villacara, 2014).  The remaining 123 patients would be evacuated the next day to supporting care providers.  Transportation was coordinated through the hospital’s emergency medical services division with New York – Presbyterian emergency medical services (Adalja, et al., 2014, July). A total of 11 hospitals received patients from New York Downtown Hospital, of which seven were system providers and four were non-system (Villacara, 2014).  The evacuation was completed within 12 hours without incident.

Upon completion of all patients, New York Downtown Hospital focused on protecting their facility so operations could resume as quickly as possible after Hurricane Sandy passed.  On October 29, the hospital turned off power and steam before Sandy made landfall (Villacara, 2014).  Minimal staff remained at the hospital in the emergency department for walk-in patients (Villacara, 2014).  On November 1, power was restored allowing for 56 beds to be available.  On November 4, the steam was restored and staff were notified that the following day the hospital would reopen to full operations (Villacara, 2014).  On November 6, surgeries are resumed at New York Downtown Hospital and would remain operational for the New York City residents recovering from the damage Hurricane Sandy left behind.

New York Downtown Hospital decided early to conduct a full evacuation when conditions were ideal.  Resources were still available to execute a plan and hospitals were not yet at capacity.  Focusing on securing the hospital and limiting the possible impact by shutting off the power and steam allowed for a more expedient recovery.

Sandy Comparative Analysis

Utilities

Bellevue Hospital recognized that their utilities were vulnerable after conducting preparedness activities for Hurricane Irene (Uppal, et al., 2013, April).  Mitigation measures were implemented to increase protection for the vital system.  However, the destructive storm surge emptied millions of gallons of water into the basement causing the pump systems to quit working (Uppal, et al., 2013, April).  The emergency generator was located on the 13^th floor and was still operational, but was not able to receive fuel from the pump system located in the basement.  Understanding how vital the emergency generator was a quick plan was developed to carry fuel to the generator to allow emergency power for the duration of the evacuation.

The pump that provided water to the hospital was not operational after water reached the basement.  Without water the care for patients became more challenging and unsanitary conditions created concerns (Ofri, 2012, December).  There was nothing that could be done until the water was pumped out of the basement and technicians were able to repair the delivery system (Ofri, 2012, December). Unfortunately, this would not occur until after the evacuation was complete and all patients were relocated.

Bellevue Hospital administration thought that they had protected the intricate pumping systems from flooding.  However, the protective actions proved to be ineffective against the massive flooding.  Overall, the importance of key components in the basement were overlooked. Additional protection measures were needed to ensure that systems would remain operational during flooding.  Water levels were six feet in most places causing pumps to be submerged (Ofri, 2012, December).  Building casing around pumping units and adding submarine-type doors proved to be not enough protection.

New York Downtown Hospital understood that they were prone to losing power if the forecasted conditions hit Manhattan (New York City, 2013).  Hospital leadership recognized they would not be able to provide adequate care to patients if power was lost.  All of lower Manhattan, where New York Downtown Hospital is located, lost commercial power after Sandy made landfall (New York City, 2013).  It is unclear if the hospital had an emergency generator. Regardless, the hospital understood their capabilities and vulnerabilities leading to the decision that patients would receive more reliable care at an alternate care site.

Communications

Communications at Bellevue Hospital were impacted after external antenna were destroyed and internal telephone equipment was demolished.  Hospital staff lost the ability to communicate by cell phone, email, or landline (Uppal, et al., 2013, April).  The use of handheld radios and runners were the only means to talk between hospital staff (Uppal, et al., 2013, April). The communications blackout was a direct result of the flooding in the basement and lack of protection of equipment.  Hospital staff were able to maintain patient care and created alternate means to communicate, but the lapse in service caused an unneeded burden to an already chaotic environment.

New York Downtown Hospital communicated with network providers, alternate care sites, state and local leaders and agencies, and the healthcare facility evacuation center in advance of the storm (Villacara, 2014).  Communicating with stakeholders prior to an emergency an ensures messages are received and understood.  Trying to communicate during an emergency can be challenging.  New York Downtown Hospital had everything coordinated before any communications issues appeared.  The advance planning proved to contribute to the success of the ability to evacuate over 100 patents within 12 hours.

Resources

Bellevue Hospital had the necessary resources to maintain care throughout the evacuation process.  There were no issues or concerns outside the loss of critical communication, water deliver, and oxygen systems located in the basement.  Staff had the essential medical equipment needed to care for patients.  Additional equipment, like oxygen tanks, were staged throughout the hospital in anticipation of outages (Hartocollis & Bernstein, 2012).  The anticipatory planning by staff and hospital leadership created a calm environment for patients.  This effort directly contributed to the continued care for patients throughout the evacuation process.

Additional resources were dispatched to Bellevue Hospital when evacuation operations were activated.  An additional 300 National Guard troops were dispatched to help in carrying patients down multiple sets of stairs to fill the ambulances that wrapped around the corner (Uppal, et al., 2013, April).  Bellevue benefited by the increased allocation of people, transportation, and supportive resources such as fuel.

New York Downtown Hospital coordinated resources in the evacuation planning process. Transportation assets were scheduled prior to landfall. Patients were sent with medications and medical records to the receiving medical centers (Villacara, 2014). The planning before evacuating patients allowed for resources to be identified and coordination between the alternate care provides.  No resource shortfalls were identified by hospital staff during the evacuation.

Political Influence

Mayor Bloomberg issued a mandatory evacuation of Zone A residents prior to Hurricane Sandy making landfall (New York City, 2013).  New York State Department of Health and New York City Department of Health and Mental Hygiene Healthcare worked side-by-side with the Healthcare Evacuation Center in the days before the storm to prepare healthcare facilities for anticipated storm impacts (New York City, 2013).  Hospital and medical centers in Zone A were asked to discharge patients ahead of the storm and shelter-in-place (New York City, 2013). New York Downtown Hospital had already planned to evacuate prior to the evacuation order.

There was no indication that Bellevue Hospital had any political pressure to evacuate prior to Sandy.  Hospital leadership were confident that protective measures taken in response to Hurricane Irene were sufficient and patients would receive better care within the hospital.  New York City ordered evacuation of Zone A which did not included Bellevue Hospital (New York City, 2013).  Evacuations had occurred for Hurricane Irene and city and state officials did not want to conduct unnecessary evacuations and putting patients in harm way (New York City, 2013).  There were no additional discussions that occurred before Hurricane Sandy made landfall.

New York Downtown Hospital decided to evacuate patients internally.  No city or state agencies asked the hospital to conduct an evacuation.  Hospital leadership assessed the risk from the storm surge and indicated that power could be lost and would cause a disturbance to ensure patients received appropriate level of care.  The capability and vulnerability assessments were the driving force behind the decision to evacuate to ensure the safety of patients and staff facing the forecasted storm surge heights.

Patient Care

Maintaining patient care capabilities is the focal point in determining what action should be taken prior to a hurricane making landfall.  Understanding the vulnerabilities of hospitals infrastructure and capabilities to combat a possible disruption allows for patients to receive treatment that is vital to their health.  Patient safety is the primary goal of hospitals regardless of the situations they may experience.

Bellevue Hospital provided essential services during the massive disruption from Hurricane Sandy.  The hospital faced many challenges that were quickly resolved with alternate means to continue care.  The loss of commercial power, limited communications, loss of water, and loss of oxygen supply system created many barriers for hospital staff to overcome. Regardless of the obstacle they faced, they continued to care for patients throughout the evacuation process until all patients were at alternate care sites.  Hospital staff and leadership did everything within their means to ensure that patients received the quality care they required throughout the storm and evacuation.

New York Downtown Hospital faced minimal challenges in conducting the evacuation. There were minor communication challenges with receiving care sites and coordinating ambulance assets, but solutions were quickly identified (Villacara, 2014).  Patients were routed to appropriate care sites using the transportation services required depending on the need. Patients received optimal care throughout the evacuation process and at their alternate care locations.

Recovery Time

Recovering hospital operations after a devastating storm can take time.  Damage to the facility dictates the time before a hospital can become operational.  It is important to understand that hospitals provide a vital service, but they are also a business.  The increase in downtime can cause the hospital financial concerns that are not projected in advance.  It is in the best interest of the hospital, from a business standpoint, to recover operations when all issues and concerns are addressed and the hospital can safely care for patients.

Bellevue Hospital received substantial damages to significant operation systems.  The hospital ended up opening components over a timeline leading to regaining full operations.  The first service that was opened was the urgent care center on November 19, 2012 (Gotanda, et al., 2015, October).   Next, a free-standing emergency department opened on December 10, 2012 allowing for the hospital to begin receiving 911-ambulances on December 24, 2012 (Gotanda, et al., 2015, October).  Impatient services would re-opened on February 7, 2013, when the hospital fully recovered from the impact of Hurricane Sandy (Gotanda, et al., 2015, October).  The staggered recovery verifies the extensive damage that occurred.

New York Downtown Hospital restored services quickly after the storm.  On November 1, 2012, power was restored and the hospital opened 56 beds for patients (Villacara, 2014).  All staff would return on November 5 and the hospital became fully operational on November 6 (Villacara, 2014).  There are many contributing factors that allow for a hospital to recover quickly and regain operational status.  First, the hospital took proactive measures to shut down critical utility systems once the evacuation was complete (Villacara, 2014).  Power and steam were turned off before the impact of Hurricane Sandy were imminent in New York City.  Second, the hospital received minimal damage. Facing less obstacles to overcome to become operation allows for quicker recovery times.

CONCLUSION

Evacuations decisions are complex and involve many factors for consideration.  A decision to evacuate patients prematurely can cause patients to be exposed to external risk, whereas waiting too long can cause patients to extreme conditions that cause unintended harm (Powell, Hanfling, & Gostin, 2012).  Competing factors can offset each other and include lost revenue to communication and logistical capabilities (Powell, Hanfling, & Gostin, 2012).  The decision is complex and requires accurate assessments of both vulnerabilities and capabilities.

Hospitals should understand their vulnerabilities and limits to providing sufficient patient care.  Additionally, hospital leadership should dissect each critical system and figuring out what impacts could cause the system to fail should be part of the vulnerability assessment.  Equally as important is a realistic assessment of the hospitals capabilities.  It is neglectful to assume that hospitals are capable of providing exemplary medical care without primary or secondary power.

Lastly, hospitals need to be receive the best metrological information from state and local emergency management agencies.  If hospitals have the ability to make their own decisions during an emergency, they should receive the best available information to base those decisions. A mechanism should be established in emergency planning to ensure those links exist and are maintained during all emergency operations.

This comparative analysis looked at two devastating hurricanes and opposing decisions for evacuation.  Two hospitals facing the same hurricane made two different discussions. Why? The answer comes down to understanding the threat from the storm and knowing the hospitals vulnerabilities and capabilities.  Sure, it is easy to look back at an event in the past and conduct and assessment leading to an alternate conclusion, but that is not the case.  Saint Charles Parish Hospital and New York Downtown Hospital both recognized that the threat they faced would not stand up against the vulnerability to their power systems (Gray & Hebert, 2007, May, Villacara, 2014).  They understood their limits.  Bellevue Hospital and Memorial Medical Center did not assess their vulnerabilities in the same way.  Memorial Medical Center had weathered many hurricanes in the past and thought Hurricane Katrina would not be any different.  They did not understand their backup power system was vulnerable and would cause very damaging cascading impacts.  Bellevue Hospital did understand the vulnerability to the pump systems located in the basemet, but implemented a mitigation measure that could not handle the massive water surge caused by Hurricane Sandy.

The opposing decisions bring to light the imperfections in making difficult decisions during uncertain times.  We do not know what will happen in the future and its impacts, but we can gather the best available information and conduct an honest assessment and build towards preparing and mitigaioning future threats.  Hospital leadership should participate in constructive conversations with stakeholders to have an honest assessment of capabilities and vulnerabilities. It is not a bad thing to recognize shortfalls and gaps, but a strength. This message needs to be pushed through the health care industry before the next hurricane makes landfall resulting in unneeded injuries or death.

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