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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This Hospital Evacuation Decision Guide is designed to:
- Provide hospital evacuation decision teamsi with organized and systematic guidance on
how to consider the many factors that bear on the decision to order an evacuation.
- Assist decision teams in identifying some of the special situations, often overlooked, that
may exist in their facility or geographic area that could affect the decision to evacuate.
No single formula or algorithm could possibly capture all of the nuances involved in the decision or
the myriad different disaster scenarios that may lead to a hospital evacuation, and this Guide does not
offer a formulaic approach to evacuation decisionmaking. Instead, the Guide is intended to
supplement hospital emergency plans, which frequently lack specific guidance on how to make that
critical decision, including what factors to consider and for how long the decision may be safely
deferred. 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 critical need for
comprehensive plans for both evacuating patients and for sheltering-in-place.
The Guide is based on an extensive literature search; discussions at an expert panel meeting;
telephone interviews with experts having hospital evacuation experiences in different types of
disasters; and a series of meetings with disaster planners, medical staff, and facilities experts from
Partners Healthcare (Massachusetts General Hospital and Brigham and Women's Hospital) in Boston.
The technical expert panel (Appendix A) also reviewed a draft version of the Guide.
The Guide includes a pre-disaster hospital self-assessment and discussions of both pre- and post-event
Pre-Disaster Hospital Self-Assessment
The Guide contains two tools, which together comprise a Pre-Disaster Self-Assessment, for use as
part of the planning process.
- The first, a Pre-Disaster Assessment of Critical Infrastructure, focuses on critical
infrastructure vulnerabilities that may affect the likelihood that a hospital would have to
evacuate, either prior to or in the aftermath of a disaster. The assessment instrument in
the Guide is divided into eight sections: municipal water, steam, electricity, natural gas,
boilers/chillers, powered life support equipment, information technology and
telecommunications, and security. The focus is on environmental systems (HVAC),
water, and electricity because they are critical for hospital operations, and their loss for an
extended period invariably triggers a need for evacuation.
- The second, an Evacuation Time Self-Assessment Worksheet, is a framework for
estimating the time required to safely evacuate all patients and focuses on a number of
factors that affect evacuation time, including: the number of patients, mix of patient
acuity, available staff, available exit routes within the hospital, patient transportation
requirements, available transportation resources (vehicles and the necessary
accompanying staff, equipment, and supplies), entry and egress points at the hospital,
road and traffic conditions, and the location of receiving care sites.
Pre-event evacuations are undertaken in advance of an impending disaster, when the hospital
structure and surrounding environment are not yet significantly compromised. As the event
progresses and conditions deteriorate, the opportunity for a safe evacuation diminishes, and
eventually decision teams must decide whether to evacuate the hospital or shelter-in-place. Deciding
whether to preemptively evacuate or shelter-in-place requires consideration of two factors:
- The nature of the event, including its expected arrival time, magnitude, area of impact, and
- The anticipated effects on both the hospital and the community, given the nature of the
event and the results of the Pre-Disaster Self-Assessment.
The Guide includes a two-part worksheet to help decision teams in this complex set of considerations.
The first part focuses on implications of different characteristics of the impending disaster. The
second part provides a framework for assessing the anticipated effects of the event on key resources
needed to care for patients (water, heat, and electricity), the overall structural integrity of the building,
and the surrounding community.
Post-event evacuations are carried out after a disaster has caused substantial damage to a hospital or
the surrounding community. As soon as possible after the event occurs, building integrity, critical
infrastructure, and other environmental factors must be assessed in order to determine whether or not
the hospital can continue to provide appropriate medical care to patients or should instead be
evacuated. The Guide includes a worksheet to help with a careful assessment of damage to the
hospital's water, sewer, electricity, and heating systems, as well as the overall building integrity, to
help decision teams decide whether an evacuation should be ordered.
Sequence of Patient Evacuation
After an evacuation is ordered, decision teams must decide the sequence in which patients should be
evacuated. The most medically fragile and resource-intensive are usually evacuated first, as soon as
appropriate transportation and staff are available. In cases where all patients are in immediate danger
and evacuation must be conducted as quickly as possible, the evidence suggests that the most mobile
patients should be evacuated first.
i The term "hospital evacuation decision team"—abbreviated in this Guide as "decision team"—is used in the
Guide to denote 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 hospital.
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