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Recommendations for a National Mass Patient and Evacuee Movement, Regulating, and Tracking System

This resource was developed by AHRQ as part of its Public Health Emergency Preparedness program, which was discontinued on June 30, 2011. Many of AHRQ's PHEP materials and activities will be supported by other Federal agencies. Notice of transfer to another agency will be posted on this site.

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1. Project Origin and Background

The Catastrophic Incident Supplement (CIS) to the National Response Framework assumes that up to 100,000 casualties may require transport, regulating, and tracking from a catastrophic incident site to health care facilities providing definitive care that are located in the surrounding community, the surrounding region, or in other parts of the country.2  The Department of Homeland Security's Interagency Security Planning Effort identified patient and evacuee mobilization planning for catastrophic events as a long-term and high-priority initiative.3 

One outcome of this planning effort was that in October 2005, the Agency for Healthcare Research and Quality (AHRQ) awarded a contract to Abt Associates and its subcontractor, Partners Healthcare, with the goal of supporting development a national strategy for the design, development, and implementation of an interagency mass patient and evacuee movement, regulating, and tracking system.  The project was undertaken with funding by the U.S. Department of Homeland Security  Federal Emergency Management Agency, and the U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response. AHRQ and the Department of Defense jointly led the project and a steering committee guided the project (Appendix A). 

AHRQ Vision

The project is consistent with AHRQ's vision to create a set of umbrella systems that fill identified information gaps in disaster planning, response, and recovery.  These systems are intended to link, but not replace, local and public-private systems and to serve as a solution in those localities where access to such systems is not currently enabled.  As such, these systems need to be designed for flexibility and interoperability with pre-existing systems in the public and private domain over a predefined problem area. The targeted problem area addressed by these systems is depicted in the diagram below.

Diagram consists of a large box labeled 'Integrated System'; in the lower left-hand quadrant is a smaller box labeled 'Local System.' Outside the left-hand side of the box, reading from top to bottom are 'Large,' 'Geographic Scale,' and 'Small.' Beneath the box, reading from left to right, are 'Low,' 'Victim Load,' and 'High.'

AHRQ has funded several systems that address this need. Two, in particular, are relevant to the project described here. The National Hospital Available Beds for Emergencies and Disasters (HAvBED) System, developed by Denver Health, provided a prototype national real-time hospital-bed tracking system to address a surge of patients during a mass casualty event. HAvBED focused on acquiring bed availability data from existing systems, rather than replacing existing systems.  An important contribution of this project was the development of data standards for defining and communicating bed availability information.

AHRQ has also funded development of planning tools that can be used to estimate resource and staffing needs resulting from disasters.  As noted earlier, one of the two goals for the Abt Associates' AHRQ project was to develop a Mass Evacuation Transportation Model that estimates the required transportation resources needed to evacuate persons from health care and other facilities.  In addition, AHRQ funded Abt Associates to create the Hospital Surge Model, which estimates the hospital resources needed to treat victims of various weapons of mass destruction scenarios.  The model is available at http://www.ahrq.gov/prep/hospsurgemodel/.

Lessons Learned from Prior Disasters

This project is also an outcome of the lessons learned from prior disasters, including hurricanes Katrina and Rita.  Four major lessons are particularly relevant to this project here. 

Need for tracking.  The Health and Social Services Committee of the New Orleans Commission recommended "generating databases with reliable and up-to-date demographic information that can contribute to enhancing hospital planning and decisionmaking during crisis situations."4  The need for information with which to plan and respond is germane both to those communities directly impacted by an event and to those communities serving as a lifeboat in accepting evacuees. The need for tracking was also emphasized by Abt Associates Inc. researchers in a recent report in which issues of separation between patient-family and family-family (in particular, children separated from parents) and the need for reunification were noted. These tracking needs are compounded by the fact that many complex evacuations across the U.S. involved an average of 3.5 moves, most of which were made across State lines.5

Need to include and integrate multiple evacuee source locations. Nursing homes are not typically incorporated into disaster-relief planning based on experience from Hurricane Andrew in 1992, the 1994 Northridge earthquake, and Hurricane Katrina in 2005.6  While hospitals are typically included in such planning activities, mandatory evacuations automatically exclude hospitals. Another report noted that hospitals become magnets for people needing help or seeking refuge during a crisis and recommended that automatic exclusion from evacuation orders be revisited and emphasized that a system for tracking evacuees is essential.7   At Tulane University during Hurricane Katrina, the numbers of individuals in need of evacuation included patients, staff, families of staff, families of patients, other nonpatients, and pets.8   Other types of evacuee source locations would include health care clinics, ambulatory surgery centers, formally designated shelters, temporary shelters such as public buildings (e.g., schools, churches, airports), hotels/motels (particularly in tourist areas), residences, and/or stranded mass transportation vehicles (i.e., trains, ships, planes).

Need for medical information. Health care workers in Houston receiving evacuees from Hurricane Katrina-affected areas found that many evacuees coming from the Superdome and other shelters arrived with pressing medical needs such as chronic illnesses, prescription fills for missing medications, replacement of eyeglasses, basic dental needs, and psychiatric services.9  Portable personal health records and/or electronic medical records that could be readily accessed from secure servers would facilitate critical health information exchange.

Need to prioritize evacuee statusMedical and social needs must be considered in triaging evacuees.  The traditional medical model for triage in the U.S. is to treat the most critically injured first; in an overwhelming disaster situations, health care providers may shift to battlefield triage practices in which those with the highest probability of survival are treated first.  Little is known about lay clinicians' abilities to shift paradigms during response.  Further, guidelines on how to consider accompanying social issues, such as maintaining family units, need to be clearly structured.  Consistent guidelines and associated protocols would support planning and decisionmaking during times of crisis.

In summary, during a disaster, data exist on patients, institutionalized individuals, and public citizens residing in or visiting a community.  Effective response in times of disaster requires that such data be readily accessible and linked to support tracking needs.  We lack the capability to exchange meaningful data across systems to facilitate evacuation holistically. The need to integrate siloed systems so that they can inform decisionmakers on sources/destinations, critical personal information, and evacuee status is emphasized by experience from prior disasters. 


2. U.S. Department of Homeland Security, National Response Plan (NRP), December 2004. (N.B., The NRP was superseded by the National Response Framework (NRF) in January 2008. The NRF is available at http://www.fema.gov/nrf. In February 2009, the CIS was undergoing review and revision to align it with the NRF.)

3. September 22, 2004 letter from the Secretary, Department of Homeland Security to Secretary, Department of Defense.

4. Health and Social Services Committee of the New Orleans Commission, 2006: "Bringing New Orleans Back: Report and Recommendations to the Commission, January 18, 2006," www.bringneworleansback.org.

5. Estimating Loss of Life from Hurricane-Related Flooding in the Greater New Orleans Area: Health Effects of Hurricane Katrina. Cambridge (MA): Abt Associates. May 2006.

6. Saliba, D, J Buchanan, RS Kington: "Function and Response of Nursing Facilities During Community Disaster," AJPH 94(8):1436-1441, 2004.

7. Gray, BH and K Hebert (The Urban Institute): "Hospitals in Hurricane Katrina, Challenges Facing Custodial Institutions in a Disaster," July, 2006, http://www.urban.org/url.cfm?ID=4113&renderforprint=1.

8. Bovender, JO and B Carey: "A Week We Don't Want to Forget: Lessons Learned from Tulane," Frontiers of Health Services Management, 23(1):3-12, Fall, 2006.

9. Van Gorder, C: "Lessons from a Tragedy," Hospitals & Health Networks, hospitalconnect.com e-newsletter, http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?derpath=HHNMAG/PubsNewsArt.


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