As recent experiences have shown – the hospital evacuations in Joplin, Missouri, and Loma Linda, California, are perhaps the best examples – the partial or complete evacuation of a healthcare facility is traumatic, complex, and extremely challenging not only for the facility itself but also for the entire local community. To evacuate a facility both quickly and effectively requires community support and many months of preplanning. During the past year, the District of Columbia Emergency Healthcare Coalition (DCEHC), recognizing that problem, has been upgrading and refining a response plan to coordinate the support of all Coalition partners for the evacuation of a hospital or other healthcare facility in the nation’s capital.
The DCEHC was created in 2007 using Coalition Partnership grant funding provided by the Office of the Assistant Secretary for Preparedness and Response (ASPR). The Coalition is composed of: (a) the city’s private-sector healthcare organizations (all city hospitals, skilled nursing facilities, community clinics, blood banks, dialysis centers, and the Poison Center); and (b) their government partners (the Department of Health, Fire/EMS, the Office of the Chief Medical Examiner, the Department of Mental Health Services, and the Homeland Security and Emergency Management Agency).
Since its inception, the Coalition has been both a planning and a response organization; an Emergency Operations Plan (EOP) serves as the doctrinal foundation for both capabilities. The EOP is based on a hazard-vulnerability analysis, which is updated every two years, and focuses primarily on system-wide risks rather than only those of individual members. Facility evacuation was one of the higher-risk components of the system that the Coalition decided to address.
A task force composed of a wide array of Coalition partners was convened and regularly met to complete two assignments. The first was to create a planning template that could be used for the evacuation of a healthcare facility – the same template could be used by hospitals and skilled nursing facilities to write their own plans for how they would organize and conduct an evacuation. The adoption of the facility-planning template was recognized by many facilities as filling a planning void that had long been neglected. In addition, because it includes standardized terminology, notification practices, and lists of operational considerations, it makes it easier for the Coalition to provide the assistance needed.
A Double-Duty Document, Two Major Assumptions & Three Primary Scenarios
The second assignment was to create a plan spelling out specifically how the Coalition should and would provide support to a single evacuating healthcare facility. The Healthcare Facility Evacuation Incident Specific Annex begins with a list of assumptions. Among them is a document that can be used: (a) to facilitate either a partial or a complete evacuation of a hospital or skilled nursing facility; and (b) to request evacuation support from healthcare organizations in neighboring Maryland and Virginia. The guidance takes into account the Coalition’s Memorandum of Understanding (MOU) in requesting and/or providing mutual aid – a pledge by facilities to help one another when able to do so.
The annex assumptions also identify three primary evacuation scenarios as being: emergent (minutes), urgent (hours), or semi-urgent and beyond (one or more days). At the heart of the Coalition’s capability to assist is the Healthcare Coalition Response Team (HCRT), which is composed of trained personnel who rotate taking weekly call as Duty Officers. The HCRT is assigned several responsibilities in its primary role of supporting a facility evacuation.
Those responsibilities include but are not necessarily limited to: providing notification to other Coalition partners about the incident; collecting data from member organizations about their resources available to assist with evacuations; serving as an interface with regional coalitions in Maryland and Virginia to collect data regarding the resources available in those states (particularly in the areas closest to Washington); facilitating patient tracking (if and when requested by the evacuating facility); facilitating the coordination of various jurisdictional response efforts; and furnishing the supporting documentation and guidance forms needed to facilitate mutual aid and cooperative assistance for the evacuating facility.
Accompanying Paperwork – Complete With Instructions
The HCRT personnel may be appointed for evacuation support, resource tracking, and patient tracking facilitation. Each position’s responsibility is defined in the Annex. An operational checklist provides HCRT members with numerous “action steps” beginning with incident recognition and initial notification/activation mobilization. The longest section focuses on incident operations, outlines some suggested action steps, and refers to a number of different forms – each of which serves a specific purpose. Included on the list are an Evacuating Facility (Supported Facility) request form, a patient checklist (for evacuating and receiving facilities); a mutual-aid offer-of-assistance form; and a form used for resource tracking at a supported facility. Other forms have been created for: (a) tracking the personnel of an evacuating facility; and (b) requesting reimbursement for the mutual aid provided. Each of these documents comes with an accompanying instruction sheet and is made available both as a printed version and electronically (on the Coalition’s intranet-based information-sharing system).
Following completion of the draft document, task force members and others used it during a tabletop exercise, then revised it in accordance with the numerous lessons learned during the exercise. The plan was used again during a functional exercise, where the scenario was the partial evacuation of a nursing home threatened by a large neighborhood fire – a number of injuries required transport to Emergency Departments, while the nursing home patients were evacuated to other nursing homes and/or to hospitals with available beds. Additional modifications were then made, based on the lessons learned during the exercise, and became part of the Coalition’s Emergency Operations Plan.
The evacuation of a hospital or skilled nursing home will never be easy. However, based on the experiences of those who have actually carried out such evacuations, having a plan in place that recognizes the need for coordinated and timely support from other healthcare facilities in the area will be essential to success. The nation’s capital is now better prepared than ever before to deal with a major mass-casualty incident – whether manmade or a whim of nature – if and when it happens. Not incidentally, the Coalition’s next priority of this type is addressing the need to respond effectively to multiple healthcare facilities requiring evacuation support all at the same time.
Craig DeAtley, PA-C, is director of the Institute for Public Health Emergency Readiness at the Washington Hospital Center, the National Capital Region’s largest hospital; he also is the emergency manager for the National Rehabilitation Hospital, administrator for the District of Columbia Emergency Health Care Coalition, and co-executive director of the Center for HICS (Hospital Incident Command System) Education and Training. He previously served, for 28 years, as an associate professor of emergency medicine at The George Washington University, and now works as an emergency department physician assistant for Best Practices, a large physician group that staffs emergency departments in Northern Virginia. In addition, he has been both a volunteer paramedic with the Fairfax County (Va.) Fire and Rescue Department and a member of the department’s Urban Search and Rescue Team. He also has served, since 1991, as the assistant medical director for the Fairfax County Police Department.