Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
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Chapter 1. Introduction
This document is designed to provide hospital evacuation decision teamsii—herein abbreviated as
"decision teams"—with organized and systematic guidance on how to consider the different factors
involved in hospital evacuation either in advance of an event, based on some degree of forewarning,
or following a disaster, if needed. The Hospital Evacuation Decision Guide is intended to
supplement hospital emergency plans, which focus on the specifics of how the hospital will shelterin-
place or carry out an evacuation once the decision to shelter-in-place or evacuate has been made.
Many individual hospital evacuation emergency plans lack specific guidance on how to make that
critical decision, including what factors to consider and for how long the decision may be safely
This Hospital Evacuation Decision Guide is not a "cookbook" and specifically does not offer a
formulaic approach to evacuation decisionmaking. No single formula or algorithm could possibly
capture all of the nuances involved in the decision or the myriad different event scenarios that may
determine the need for evacuation. In some situations, the decision to evacuate is clear and obvious,
such as a fire or major infrastructure damage that places patients and staff at risk. No decision guide
is needed for these situations. This Hospital Evacuation Decision Guide is intended to provide
assistance in those instances when the decision is not clear—when the uncertainty of the event and its
aftermath may result in compelling arguments both for and against hospital evacuation.
This Guide does not recommend or present best practices for carrying out an evacuation or for
sheltering-in-place during and after a disaster, other than to stress the importance of having
comprehensive evacuation and shelter-in-place plans. The reader is referred to other publications for
advice on developing and executing evacuation plansiii and shelter-in-place plans.iv
An additional role of this Hospital Evacuation Decision Guide is to assist decision teams in
identifying some of the special situations, often overlooked, that may exist in their facility or
geographic area and that could affect the decision to evacuate. Identifying these specific
considerations, and planning in advance to take them into account during decisionmaking, may better
prepare leadership to make an evacuation decision, should the need arise.
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An extensive literature search was conducted to identify all relevant material about hospital
evacuations and decisionmaking during disasters affecting a single hospital or an entire region. Peerreviewed
journals and trade publications, as well as government reports, working papers, and other
"gray"literature, were all included in the search.
An in-person meeting of an expert panel was convened in Washington, D.C., in January 2009.
Panelists representing appropriate Federal agencies participated, as well as many hospital leaders who
had experienced evacuations and researchers who have studied disaster evacuations. In the
subsequent months, additional telephone interviews were conducted with experts having a wide array
of hospital evacuation experiences (e.g., hurricanes, earthquakes, fires, floods). Finally, a series of
meetings were held with disaster planners, as well as medical and facilities experts from Partners
Healthcare (Massachusetts General Hospital and Brigham and Women's Hospital) in Boston,
Massachusetts. The expert panel also reviewed a draft version of the Guide. A list of panel members
is in Appendix A.
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Types of Disasters vs. Reasons for Evacuation
It is important to distinguish the type of event or disaster that could lead a decision team to consider
evacuation (e.g., earthquake, flood), as distinct from the ultimate reason for the evacuation (e.g.,
structural damage, loss of municipal water).
In theory, any of the various types of disasters listed in Table 1 could lead a decision team to consider
evacuating patients, either prior to an event or in the aftermath of the event. In this Guide, we
distinguish between "Advanced Warning Events"and "No Advanced Warning Events."With
Advanced Warning Events, decision teams have time prior to the event to make evacuation decisions.
Hurricanes are the most common example of an Advanced Warning Event. With earthquakes,
tornadoes, and other instances of No Advanced Warning Events, decisions must often be made very
quickly, either in the midst of the disaster or immediately afterward.v
Types of Disasters1
- Thunderstorms and
- Winter Storms and
- Extreme Cold
- Extreme Heat
- Landslide and Debris
- Flow (Mudslide)
- Hazardous Materials
- Nuclear Power Plants
- Biological Threats
- Chemical Threats
- Nuclear Blast
- Radiological Dispersion
The type of event precipitating an evacuation is typically well publicized. It is widely known, for
example, that several hospitals evacuated their patients in the aftermath of Hurricane Katrina in 2005,
and prior to Hurricane Gustav making landfall in 2008. What is less clear is the ultimate reason—or
set of circumstances—that prompted many documented evacuations. In the case of the flooding
following Hurricane Katrina, New Orleans hospitals evacuated when they lost city water, lost all
power, or were unable to ensure the safety of patients and staff in the midst of civil unrest. After
careful examination, it is clear that it was not the hurricane or the subsequent flood that caused
decision teams to order hospital evacuations but the damage to hospitals and critical infrastructure, as
well as problems in the surrounding community.
Table 2 lists some instances of hospital evacuations, the type of disaster that preceded the evacuation,
whether (in the case of Advanced Warning Events) decision teams decided to evacuate prior to the
event, whether the evacuation took place after the event, and the ultimate reason(s) for the evacuation.
Table 2 is intended to be illustrative and not a comprehensive listing of all hospital evacuations. In
particular, not shown are the many instances in which decision teams seriously considered evacuating
but, in the end, decided not to. Table 2—and, more generally, this Guide—does not address
operational aspects of how these evacuations were executed, such as which local, State, or Federal
assets were used to evacuate patients.
Table 2 highlights the importance of critical infrastructure, in particular the water supply, in many
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The remainder of this report is organized into three chapters:
- A Pre-Disaster Hospital Self-Assessment is discussed in Chapter 2. The self-assessment
should be completed as part of a hospital's disaster preparation and planning
efforts. It focuses on critical infrastructure and assets that are of specific concern with
respect to evacuation. It is intended to help decision teams identify vulnerabilities that
affect the likelihood that a hospital would have to evacuate as well as specific challenges
a hospital may face during evacuation, either prior to or in the aftermath of a disaster.
The self-assessment and accompanying text also provide assistance in estimating the time
required to evacuate patients from the hospital and relocate them to other facilities.
Being able to form an accurate estimate of the time required to evacuate is a critical
component of the decision to evacuate.
- Pre-event evacuations, an option in the case of Advanced Warning Events, are discussed
in Chapter 3. For pre-event evacuations, the self-assessment of vulnerabilities and the
scope/scale of the impending event are the key factors to consider. Chapter 3 includes
guidance on whether—and when—to preemptively evacuate patients prior to an event, as
well as on the accompanying decision regarding the sequence in which patients should be
evacuated (i.e., who goes first).
- Chapter 4 addresses post-event evacuations, which could occur either 1) with an
Advanced Warning Event in which decision teams decide to shelter-in-place during the
event and subsequently realize the need to evacuate, or 2) following a No Advanced
Table 3 is a list of Guide terminology and acronyms.
ii The "hospital evacuation decision team"—abbreviated in this Guide as "decision team"—denotes the
persons in charge of planning for an evacuation well in advance of an incident, as well as the persons who
ultimately decide whether to evacuate a hospital during an incident. In reality, the Incident Commander—who is often a senior hospital administrator—would make this decision in conjunction with senior hospital
staff and emergency management and response officials if the hospital has activated its Emergency
Operations Plan and is operating according to the Hospital Incident Command System (HICS). Developed
by the California EMS Authority, HICS is a methodology for using the Incident Command System (ICS) in
a hospital environment that is consistent with the National Incident Management System. Within the ICS
management framework, the Incident Commander has overall responsibility for managing the incident,
which for the purposes of this Guide refers to the event that precipitated a possible evacuation of the
iii For examples, go to the California Emergency Medical Services Authority's Evacuation Planning Scenario
(http://www.emsa.ca.gov/HICS/files/Int_02.pdf [PDF Help]), the New York City Hospital Evacuation Protocol
(http://www.nyc.gov/html/doh/downloads/pdf/bhpp/bhpp-hospital-nyctpevac-plan.pdf [PDF Help]), and the California
Hospital Association's hospital evacuation template
iv For example, the California Hospital Association's shelter-in-place checklist
v Situations in which a decision team considered evacuating, but ultimately decided not to, are less likely to
be documented in the literature; we therefore do not know the true breadth of disaster circumstances that
led decision teams to consider evacuation but ultimately decide against it.
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