Sexton, Karen H. PhD; Alperin, Lynn M.; Stobo, John D. MD
In terms of lives lost, the hurricane that struck Galveston, Texas, in 1900 remains the most devastating disaster—natural or otherwise—experienced in this country. Estimates place the human death toll at more than 6,000.1 A century later, the new millennium has ushered in a host of new disasters worldwide: 9/11, bioterrorism, deadly emerging viruses, and intense natural calamities, such as the 2004 tsunami in the Indian Ocean. In the United States, the anthrax attacks of 2001 and, more recently, Hurricane Katrina (which killed an estimated 1,100 and severely disrupted the lives of countless more) demonstrated dramatically the limitations of the U.S. health care system to respond effectively to large-scale public health emergencies.2 Moreover, the 2005 hurricane season, unprecedented in both the number and magnitude of storms, made painfully clear the importance of adequate disaster preparedness for coastal communities.
The White House report on Hurricane Katrina, released February 23, 2006, calls for “a more concentrated push to evacuate hospitals and nursing homes,” recommending that “the disabled, the sick and the elderly must be included in evacuation plans, and drills must take place to ensure that the plans will work.”3 As crucial members of the health care community, physicians should be aware of the evacuation processes at their own institutions and the expectations for their participation in these processes. We describe here the first evacuation in the 114-year history of the University of Texas Medical Branch at Galveston (UTMB), including how and why UTMB succeeded and what lessons were learned.
UTMB was established in 1891. Today, UTMB consists of four schools, six campus hospitals with a combined 730-bed capacity, three institutes, a network of more than 100 campus- and community-based clinics, 12,000 faculty and staff, and 2,900 students and house staff. The campus houses biosafety laboratories (levels one through four)and one of two national biodefense laboratories is currently under construction here. Galveston Island, where UTMB is situated, is protected by a 100-year-old seawall that rises 17 feet above mean low tide.1
After the 1900 hurricane, UTMB had developed a strongly entrenched storm-preparedness mentality. Over the next 105 years, the hurricane protocol was to discharge the healthiest patients, keep in the hospital and care for the most seriously ill, and “hunker down” to ride out the storm. Although UTMB had a disaster plan, total evacuation of its hospitals had never been part of it.
In March 2005, after four hurricanes and one tropical storm had hammered Florida the previous season, the Texas legislature gave the governor authority to declare states of emergency and to issue mandatory evacuation orders should a comparable natural disaster strike Texas in the future. After this legislation passed, local governments and agencies in the coastal areas were instructed to develop emergency plans. Charged with creating its first evacuation plan ever, UTMB had requested additional time to complete this daunting task. As Hurricane Rita barreled toward Galveston in September 2005, threatening to put UTMB's disaster preparedness to the test, our evacuation plan was merely a “work in progress.”
On Sunday, September 18, 2005, local and state officials predicted that what was then Tropical Storm Rita would make landfall on the central Texas coast; by Monday morning (four days before landfall), the storm had graduated into a full-fledged hurricane, and landfall was predicted for the upper Texas coast, where UTMB is located. Threatened for the first time by the possibility of a category five hurricane with 20-foot storm surges that carried the potential to inundate the island, UTMB leadership was determined to avoid the disastrous outcomes of Hurricane Katrina, which had devastated areas of the Louisiana, Mississippi, and Alabama coasts just weeks earlier.
One component of the UTMB disaster preparedness plan was the identification of an individual to serve as the incident commander. This experienced clinician was appointed by the university president from the university's executive leadership team and was given sole decision-making authority during the emergency. By late Monday morning, UTMB's incident commander instructed staff to begin preparing any eligible patients to be discharged and to cancel any procedures that would require patients to be hospitalized longer than 48 hours. All clinic appointments for ambulatory patients slated for later in the week were rescheduled.
On Tuesday afternoon (three days before landfall), as specified in the UTMB emergency operations plan, the incident command center, which functioned as the decision-making and communication hub throughout the storm, was activated. The center, located in the heart of the hospital complex, housed the incident commander (the single person responsible for making and communicating decisions, and the primary spokesperson throughout the storm), as well as an incident-response team comprising key representatives from the medical, communications, safety, security, logistics, planning, operations, and finance arms of the enterprise. The same day, all institutional units were advised to activate their area-specific emergency plans and to provide the incident command center with a list of essential personnel (those employees who remain on-site to maintain critical functions during a declared emergency). All students were dismissed, and nonessential personnel were released at the end of the day. Plans were implemented to close and decontaminate the biosafety level three and level four laboratories, and assessment of the remaining inpatients began.
Late Tuesday evening, UTMB officials participated in a conference call with the Texas Department of Public Safety's Division of Emergency Management, during which they learned that the governor planned to declare a state of emergency within 24 hours. State officials were able to guarantee the ground and air transportation needed to safely evacuate the remaining patients, provided UTMB could commit immediately to a Wednesday morning (two days before landfall) evacuation. The incident commander negotiated for additional time. Her goal was to avoid transporting any gravely ill patient unless absolutely necessary. State officials agreed to wait until 7 am Wednesday morning, when she would have the benefit of the most up-to-date weather report.
University personnel immediately contacted SETON Health Care Network, which consists of multiple medical facilities in central Texas (including four hospitals in Austin) and which had recently entered into a 30-year affiliation agreement for graduate medical education with UTMB. The SETON partners were notified that UTMB might need to transfer patients to their facilities the following day and were asked to determine how many and what type of patients they could receive. Staff at SETON worked throughout the night to evaluate their capacity and prepare for transfers. On Wednesday morning, SETON informed UTMB they would be able to accept 30 patients; in fact, they took 170 patients, including most of UTMB's sickest neonates and children. Many other medical facilities followed suit.
At UTMB, physicians and hospital staff also worked throughout Tuesday night and Wednesday morning to assess all patients, determine which should be evacuated first, and write discharge orders and transfer notes. Physicians and staff copied pertinent medical records and provided medications, and all patients (except those receiving correctional care, as discussed later) were transported with paper copies of their medical records and lists of current medications.
Shortly after 7 am on Wednesday (two days before landfall), Hurricane Rita was a category four storm gathering steam when the incident commander decided to evacuate all patients. Three staging areas to facilitate the evacuation were established to ensure patient safety. The first was at the bedside, the second at the hospital exit, and the third where patients were loaded onto ground or air transportation. By 8 am, patients had been prioritized and prepared for transport at the first staging area; at 9:30 am, the first patient was evacuated by helicopter. Ten hours later, UTMB physicians and staff had successfully evacuated 427 patients.
Physicians and nurses determined the appropriate mode of transport for each patient and decided what type of life-support systems and other medical assistance each patient might require en route. Unit nurses contacted the incident command center when a patient was ready to be transferred to the second staging area. A command center employee responsible for matching patients with available beds recorded where each patient was going, the type of transport involved, and when the patient left UTMB. That employee then alerted the receiving hospital that a patient was on the way and notified the nursing staff responsible for calling patients' families with the intended destination of the patient. Intensive care unit patients were evacuated by air through the emergency department entrance and helipads on campus. Other medical and surgical patients left through the front entrance of the hospital via ground transportation. Separate staging areas on the island had been arranged for more than 90 ambulances, 32 helicopters, six fixed-wing aircraft, and buses and numerous passenger vans, which waited to be dispatched to the campus.
Employee safety became the priority once all of the patients had been evacuated, and the incident commander decided to release any employee who wanted to leave. By this time, many Galveston residents and UTMB employees who had left the island on Wednesday were stranded in gridlocked traffic caused by inland evacuation and lack of fuel. UTMB leadership sought alternative solutions to ground evacuation and requested air evacuation from the state operations center, which they agreed to provide early Thursday morning (one day before landfall).
With the state's approval, to supply air evacuation, the incident commander gave all remaining employees three options: stay voluntarily in the hospital for the duration of the storm, leave on their own, or be evacuated by air. The Air National Guard dispatched two C-130 planes to Ellington Field, 30 miles away. Employees who chose air evacuation were shuttled to the airfield and flown to Fort Worth, where members of the incident command center had arranged shelter that morning with the state's assistance. In all, approximately 300 essential employees chose to leave, 132 via air transport. The 400 remaining employees, including UTMB's president and his wife, registered with the incident command center and were on hand to maintain critical campus systems; to communicate with employees on-site, throughout the state and beyond, and with the public at large; and to keep the emergency room open for Galveston residents, local emergency personnel, city officials, and reporters covering the hurricane. (At midnight, the operating room was opened to treat an acute burn victim from a downtown fire that occurred at the height of the storm; that patient was transferred to a hospital in Lubbock, Texas, on Saturday.)
By the end of Thursday (the night before high winds began to move onshore), the campus was fully locked down, including areas within the hospital where equipment and supplies—including pharmaceuticals from decentralized patient-care areas—could be secured and closely monitored. The only exception was a single entrance to the hospital complex manned by campus police. A sign-in/sign-out system ensured that the incident commander had an accurate count at all times of employees on campus. By then, Hurricane Rita had begun tracking east of Galveston; by the time the brunt of the hurricane came ashore on Friday afternoon and evening, it had been downgraded to a “dangerous” category three storm, sparing the island the worst of the high winds and storm surge.
At 3 pm on Saturday (one day after landfall), UTMB officials announced they would lift emergency status as of 8 am the following Tuesday, September 27. Then began the important process of addressing minor physical damage to the campus, recalling faculty and staff to relieve essential personnel who had remained at UTMB during the storm, notifying students to return for classes, making arrangements to transport evacuated patients and employees back to Galveston, and resuming clinical operations. Underlying this new phase of activity was a shared sense of relief that the island and the institution had dodged a potentially lethal bullet. The UTMB hospitals began accepting inpatients Tuesday (three days after landfall) and resumed clinic appointments the next day. One week after the storm, UTMB's hospital complex was operating at 80% of normal capacity.
Factors Crucial for Success
What turned out to be a real-life “dress rehearsal” of a total hospital evacuation taught us valuable lessons. We hope that sharing what we learned may inspire other health care teams to consider and further refine their own emergency preparedness plans. Ironically, the fact that UTMB's disaster plan did not specifically provide for evacuation at the time of Hurricane Rita may have inspired some of the strategies that contributed to the successful evacuation. Several of the strategies we consciously employed or that happened upon along the way are noteworthy.
Authorizing an undisputed incident commander
First and foremost, identify an incident commander. Having a single person in charge—a leader who is decisive, clear, and confident the job can be accomplished—is essential. This person must be given sole authority for decision-making. He or she should also have clinical experience and occupy an executive leadership position. At UTMB, the incident commander was a nurse and the chief executive officer for the clinical complex.
Developing and communicating guiding principles
Develop and communicate a set of guiding principles to frame every decision that leadership, physicians, and staff must make on a minute-by-minute basis. Ours were simple. First, patient safety was paramount. To that end, we evacuated the most critically ill patients first. Second, every patient would be transported via the appropriate mode, and with the proper identification and pertinent medical information. We went to great pains to ensure that all patients left with paper copies of their medical records and discharge orders. Third, no patient would be lost, geographically or otherwise. We sent hospital staff with patients when they required more attention than transport personnel or receiving hospitals could provide. We tracked patients throughout transfer and notified their families of the patients' destinations. Fourth, employee safety was paramount once all patients were evacuated. Finally, with the exception of the main hospital complex, all facilities were locked down to consolidate essential activities, including security and communications.
Establishing a comprehensive incident command center
Establish an incident command center, one that consolidates vital institutional functions under one roof. The center houses the high- and low-tech systems to effectively communicate decisions and developments internally and externally, as well as a centralized data repository to keep track of evacuated patients and on-site personnel.
Avoiding delay in deciding to evacuate
Do not delay the decision to evacuate or worry about anyone second guessing the decision. The sooner you give physicians and staff the “green light,” the greater the likelihood that the evacuation will proceed according to your guiding principles and emergency plan. Base the decision on patient and employee safety rather than on financial considerations. Although the evacuation cost UTMB $17 million, primarily in lost revenue, leadership would make the same decision again given similar circumstances.
Identifying strategic partners in advance
Although any institution must be prepared to handle any eventuality on its own, the value of partnerships cannot be overstated. Identify strategic partners well in advance. They are a crucial element in a well-designed evacuation plan because successful evacuation of critical- and acute-care patients can be accomplished only if another facility outside the disaster area will accept them. Identifying a single point of contact at the receiving hospitals is also necessary. The value of good partners was illustrated admirably by the SETON Health Care Network, which had initially agreed to accept 30 of our patients. To accommodate our greater needs during the emergency, the responsible contact at SETON arranged to discharge enough of their patients to allow them to actually receive 170 of our most critically ill patients.
An article4 published several years ago notes the following:
Although health care institutions have responded to regional catastrophes for decades, hospitals have more typically responded as individual institutions to local crises. Health care institutions must now learn to function as coordinated components of a regional response to crises that are more far-reaching. With this new role comes a host of issues, including education, communication, and institutional response, all requiring innovative solutions.
Fostering a community of equals
Foster a sense of productive community, defined as a community of equals in which each is valued for what he or she contributes and false differences created by title or position disappear. Although identifying the one person ultimately responsible for making and communicating decisions is imperative, remembering that everyone plays a critical role and needs to understand the significance of his or her contribution to the task at hand is equally important.
Note that key members of our incident-response team had recently received crew resource management (CRM) training. Developed by the aviation industry about 25 years ago to ensure greater safety for passengers, CRM is concerned primarily with the cognitive and interpersonal skills needed to gain and maintain situational awareness, solve problems, work as a team, and make decisions. “Interpersonal skills are regarded as communications and a range of behavioural activities associated with teamwork. In aviation, as in other walks of life, these skill areas often overlap with each other, and they also overlap with technical skills.”5 The application of the principles of CRM to the medical setting have been recognized for some time now.6,7 These principles taught UTMB leadership the value of a checklist or “roadmap” in dealing with an emergency situation. Checklists developed for each of the three patient-staging areas enabled hospital personnel to keep track of all evacuated patients. Furthermore, the checklists helped to standardize the evacuation process so that personnel were guided through all necessary steps in assessing and moving patients.
Selecting essential personnel carefully
Designate essential personnel carefully, making sure they will not be distracted during the emergency by personal health issues or significant family concerns (e.g., being the sole caregiver of dependents). A well-designed evacuation plan should factor in the safe transport of “excess” personnel in the event you have more faculty and staff on hand than you need to maintain core functions once the patients have been evacuated.
Conducting periodic trial runs
Conduct trial runs of your emergency preparedness plan on a regular basis to identify flaws in the plan and to ensure that essential participants are familiar with protocol.
Deficits Undergoing Continuous Improvement
The complexity of effectively communicating during the evacuation to countless individuals, both within UTMB and beyond, probably accounts for most of what did not work as well as we would have liked. We are now addressing the following issues that were problematic during the evacuation.
Operability of communication devices
One unhappy discovery during the evacuation was that some of our communication devices (walkie-talkies, cell phones) were either outdated or did not work in too many “dead” areas of the hospital. Also, some emergency outlets did not work. Trial runs would have probably revealed these problems, and we could have addressed them before a category five hurricane was approaching.
We believe we could have done a better job communicating with each other and with external stakeholders (such as family members, receiving hospitals, and others) about the patients being transported. We were well aware of the evacuation-related traffic gridlock taking place. In fact, the incident commander contacted the state's emergency-management personnel and an elected official to see whether they could open an emergency lane for ambulances, which proved impossible. Consequently, we had no way of knowing which ambulances (and patients) were stuck in traffic and which were not. In some cases, we were unaware of decisions made by emergency medical service personnel to reroute a patient to another health center. Our lack of knowledge hindered our ability to communicate effectively with family members.
Standardization of database format and software
We would have benefited from having a standard format and single database for capturing data regarding patient transport, on-site personnel, and other critical information. Although we transmitted medical records for correctional care electronically to the receiving facility in Tyler, Texas, the prison there did not have the proper software or equipment with which to access these records. A system making data retrieval easier and more efficient would have improved our communications with hospitals that were receiving (and later returning) our patients and would have helped us identify, appropriately track hours worked by, and compensate essential personnel. We are now implementing electronic medical records for all our patients and are working to achieve the standardization needed for more satisfactory communication with our partners.
UTMB continues to field requests from health care and community organizations nationwide who are interested in learning from our experience. And, as we prepare for the predicted series of active hurricane seasons, university leadership and emergency preparedness officers continue to refine the plan and related procedures on the basis of our experience during Hurricane Rita. Ultimately, we hope our evacuation experience will raise awareness among the medical community and encourage physicians, as critical members of the health care team, to think creatively about ways to better prepare for and respond to emergencies.
The authors would like to thank Christine F. Comer, associate vice president for public affairs, University of Texas Medical Branch, for her invaluable editing assistance.