In August 2009, 55-year-old Wesley Stanko was admitted to Chinook Regional Hospital in Lethbridge, Alberta, Canada, after a fall. Stanko had suffered from a brain injury and struggled with declining health for some time, but prior to being admitted to the hospital was still able to live independently. At some point during his stay, he shuffled out of his room unnoticed, and a search was initiated soon after his disappearance. Some hospital staff did not believe he was in any immediate danger, and assumed that he had gone to visit friends. Almost three days later, he was found trapped – but alive – in a hospital mechanical room. He was subsequently moved to a long-term care facility where he could be monitored more closely in the future.
The following month in Essex, England, a similar but more tragic incident unfolded. An unnamed 53-year-old man suffering from breathing problems was admitted to Colchester General Hospital on the evening of 12 September. After he had been transferred to several departments throughout the night the hospital staff noticed, just before 4:00 a.m., that he was suddenly missing. The police were notified and a search was initiated. His body was discovered by a staff member the next morning in a locked section of the hospital’s outpatient department.
These two stories underscore just a few of the challenges involved in tracking patients during nonemergency operations on a typical working day at almost any hospital. However, during times of emergencies or disasters, the challenges of patient tracking increase exponentially and require extensive internal and external coordination in the resulting chaotic environment. The degree of difficulty in patient tracking is largely determined, in most such situations, both by the unique challenges posed by each disaster and the acuity of each patient.
As illustrated in the examples cited above, patients are difficult to track without the right tools. In the past decade, disasters such as Hurricane Katrina have prompted the development, fortunately, of the more effective processes made possible by emerging technology. This improved tracking capability will undoubtedly not only provide substantial benefits to daily hospital operations, but also lead to more effective and more efficient mass evacuation operations.
Healthcare Facility Evacuations and Patient Tracking
There is a broad spectrum of emergencies that may force a healthcare facility to evacuate some or all of its patients. Internal hazards such as fire, smoke, and/or the release of hazardous materials can create an unsafe environment. In addition, the loss of environmental services – e.g., utilities, sterilization, communications, and IT support, the loss of medical gases, or threats to physical safety (e.g., a violent or armed visitor) – may well require evacuations, if only to sustain patient support and safety.
The type of evacuation and immediacy of action required depend on many factors, including the location and severity of the threat or hazard. In spatial terms, an evacuation may be: (a) horizontal – moving from one area to another on the same floor; (b) vertical – moving patients from one floor to another; or (c) a partial or complete evacuation of the facility – which might well be required during major emergencies such as natural disasters, multi-casualty accidents, or acts of terrorism that threaten facility stability or access.
In timeline terms, the evacuation process may be: (a) immediate – for threats such as fires; or (b) delayed – for more prolonged hazards such as the loss of utilities. Regardless of the type of evacuation, the key to successful patient tracking during evacuation operations is to have a plan already in place, ahead of time, that is not only understood by all parties involved but also has been previously exercised – by the same staff members. The emergence of new tracking technology is expected to further enhance these processes.
Also now available are a number of rapidly evolving tracking systems and other technology-enabled support tools that have been developed by the federal government as well as by many states. The state systems, which are often quickly available to local responders and healthcare facilities, are used by local and state response agencies to initiate and manage evacuation operations. These systems include but are not limited to: the “At Risk Registry” in Louisiana; the Emergency Status System (ESS) in Florida; and the Texas Evacuee Tracking Network (TxETN).
In scenarios requiring larger evacuations and/or operations across greater distances, a federal patient tracking system known as the Joint Patient Assessment and Tracking System (JPATS) may also be used. JPATS was developed through an interagency agreement between the Department of Defense and the Department of Health and Human Services.
Texas Tracking
Hurricanes are a primary threat to the state of Texas, which has over 350 miles of general coastline and 3,300 miles of tidal shoreline. Largely for that reason, the threats posed by hurricanes are a central focus of the state’s preparedness programs. Texas officials have taken many of the lessons learned from Hurricanes Katrina and Rita to establish new plans and concepts of operation. A new patient tracking system – the previously mentioned TxETN – was developed, for example, and was first used during Hurricanes Gustav and Ike. A flexible system that continues to evolve, it can be used for applications ranging from a hospital evacuation to general shelter-management operations.
Politically, the TxETN is a partnership overseen by the Texas Department of Emergency Management and the Texas Department of State Health Services. The primary hardware contractor, Radiant RFID, worked closely with the developers of the EMTrack and Evac Center software programs – and with the Southwest Texas Regional Advisory Council (STRAC), and the Sabine Neches Chiefs Association – to build the interoperable hardware and software components that support the patient tracking network. By leveraging these relationships and that technology, the established process is both fast and simple.
In a hurricane scenario, an Embarkation Hub can be established for anyone who is unable to self-evacuate – i.e., persons with medical, functional, or other needs that prevent them from evacuating. Upon arrival at the hub, those persons are triaged and their basic information – name, address, gender, date of birth, etc. – is entered into the tracking system. In some cases, the strip on the back of the Texas driver’s license can be swiped to load the information automatically. That information is then electronically associated with the person’s barcoded wristband, which is embedded with a radio frequency identification device (RFID); the wristband then becomes the person’s “ticket” for evacuation and return.
A triage algorithm is used to determine the most appropriate form of available transportation – e.g., buses, ambulances, and/or aircraft (fixed-wing or helicopter) – for those with medical or functional needs. The transportation assets usually are equipped with not only barcodes but also a Global Positioning System (GPS) device. As evacuees/patients are loaded into, or onto, whatever transportation is available, their wristbands are scanned by either a handheld scanner or an RFID Portal (which looks somewhat like a security portal at a supermarket). When a banded evacuee passes through the portal, it automatically reads his or her information through an antenna in the portal and forwards the information to an evacuee database, further reducing the processing time needed.
After the transportation vehicle is loaded with evacuees, the TxETN system automatically generates a manifest. Throughout the trip, there is real-time monitoring of the transportation vehicle through its GPS. When evacuees arrive at the debarkation point, they again pass through a portal – where the system is automatically updated to ensure, and to reflect the fact, that each evacuee has arrived. A separate tag is also available for each wristband, and can be used to tag durable medical equipment items that evacuees may require. The extra tag also can be used to keep track of a pet.
The tagging process not only enhances the accuracy of patient tracking during an evacuation but also offers valuable search capabilities. Using the wristband tags requires less manpower and provides remarkable situational awareness information to key response organizations. At any moment, the Incident Commander knows how many and what type of evacuees he or she is monitoring, as well as their current locations and planned destinations. Those managing both medical and general population shelters also know, exactly and automatically, what evacuees are on the way in, when they will arrive, and what types of support they may require.
Interfacing Management Tools for Patient Evacuations
WebEOC by ESi is an incident management tool generally employed throughout the state of Texas by emergency managers and their response partners to manage both incident and asset information in a systematic fashion. Today, though, there are more than 40 separate WebEOC servers across the state, an abundance of assets that on occasion, unfortunately, causes some serious interoperability and coordination challenges. However, those challenges have been efficiently addressed by the Southwest Texas Regional Advisory Council (STRAC) over the past several years through what is called the Texas WebEOC Interoperability Project (TWIRP). This project has increased interoperability and decreased system redundancy across the entire Texas WebEOC network.
The TWIRP Project established fusion servers to serve as the hubs needed for sharing information between and among the statewide servers. The much improved connectivity was recently expanded, by using ESiWebFUSION, to all FEMA Region 6 states (Texas, Arkansas, Louisiana, Oklahoma, and New Mexico). Those states are now connected and are able to not only share critical information but also to maintain a common operating picture throughout the region. The TWIRP also facilitated an interface with EM Track, which is used by many local hospitals as a patient evacuee tracking system, and with the database servers for the Radiant RFID system. The interoperability thus achieved plays a critical role in the statewide sharing of information on patient evacuations.
In short, the future of patient tracking looks promising. Moreover, as key partners continue to leverage technology to develop even more effective tracking processes, and as those technologies further simplify and speed up the processes, mass patient evacuations will become considerably more manageable. The most essential step, probably, that now should be taken by areas without such systems in place is to cultivate the partnerships that will facilitate the standardization of evacuation processes. For emergency managers, it is comforting to know that, after a common set of patient evacuation priorities and objectives has been determined, the technology needed to make it happen will already be available.
Bruce Clements
Bruce Clements is the Public Health Preparedness Director for the Texas Department of State Health Services in Austin, Texas, and in that post is responsible for health and medical preparedness and response programs ranging from pandemic influenza to the health impact of hurricanes. A well-known speaker and writer, he also serves as adjunct faculty at the Saint Louis University Institute for BioSecurity. His most recent book, Disasters and Public Health: Planning and Response, was released in 2009.
