Rapid nighttime evacuation of a veterans hospital

TheJoumai of EmergencyMedione, Vol 3 pp 387-394, 1985 Prlntedin the USA ??CopyrIght ‘@1985 PergamonPressLtd

~-.~~.

Disaster

Management

RAPID NIGHTTIME EVACUATION OF A VETERANS HOSPITAL Martin J. Blaser, MD, and Richard T. Ellison

III, MD

Medical Service, Veterans Admlnlstratlon MedIcal Center, and the DIVISIONof lnfectlous Diseases Department of Medicine. Unwerslty of Colorado School of Medicine, Denver Repnnt address: Martin J Blaser, MD, Infectious Disease Section (111 L). Veterans Admlnlstratlon MedIcal Center, 1055 Clermont Street, Denver, CO 80220

0 Abstract-Loss of essential utilities and danger of explosion forced a rapid nighttime winter evacuation of 229 patients from an acute-care Veterans Administration hospital. Although distribution of patients to recipient hospitals was not optimal, and the location of several patients could not be documented for more than 24 hours, the evacuation in subfreezing weather went smoothly. Continuity of care and careful planning permitted an orderly return to the hospital five days later. Although financial costs were high, no excess mortality or morbidity was associated with the evacuation. No changes in pharyngeal gram-negative bacterial flora of the patients were noted. Further, a critique is presented to aid in planning for similar emergencies elsewhere. 0 Keywords -evacuation; Veterans Administration; disasters; disaster planning; hospital infections

Introduction Hospital evacuations are not common, and the necessity for emergency evacuations is with other domirarer still.lm4 Compared ciliary institutions, evacuations from hospitals pose special problems. The most important constraints concern the transport

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of sick, often critically ill persons, arrangements for appropriate facilities to receive them,5 and the subsequent reversal of the process to ensure an orderly readmission. Recently our hospital underwent a rapid evacuation because of emergency conditions. The purpose of this report is to describe the events that occurred, to provide an analysis of the key steps in the process, and to assess the impact of the evacuation on both the patients and the institution.

Description

of the Evacuation

The Denver Veterans Administration Medical Center (DVAMC) is a nine-story tertiary care general medical, surgical, and psychiatric facility. Ordinarily the bed census is 425, but because of a major renovation and construction project, the number of beds on December 15, 1983, was 268. At 2115 hours on that night, the hospital administration was informed of a flood in the subbasement. Despite pumping by the Denver Fire Department, the water continued to rise and the source of the flood could not be determined. Within the next hour it became clear that the hospital was without

Disaster Management features articles addressing the role of emergency medicine personnel in a disaster. This section is coordinated by Peter T. Pow, MD, of the University of Colorado Health Sciences Center, Denver, CO.

RECEIVED: 1 July 1985; ACCEPTED: 24 September 387

1985

0736.4679/85

$3.00

+ .OO

388

water, fire protection, and vacuum for suction. Further, the continued rise of the water threatened the electrical and steam pipe system with the possibility of explosions. As a result, at 2330 hours the decision to evacuate the hospital was made. Fortunately, this decision was made about the time of an employee shift change, and all nursing service personnel from the evening shift remained at their stations, ensuring a large manpower pool. Based on the rate of water rise, it was estimated that two hours remained until the electric power might be lost, leaving the hospital cold, dark, and without elevators. Several steps were promptly taken: an inventory of the medical and transport status of patients was done, a command post was established in the administrative offices, a call-in chain (contacting divisional heads who contacted other personnel according to a predetermined pyramidal network) was initiated to bring key personnel to the hospital, and a second administrative team began to mobilize ambulances and to identify empty beds at other area hospitals. Their aim was to disperse the patients to a few nearby hospitals, including the Fitzsimons Army Medical Center that had the capability to absorb most if not all patients. At 0015 hours on December 16, a city-wide emergency was declared by the Denver Director of Public Safety, and the Denver Office of Emergency Preparedness assumed control of the evacuation. In addition to ambulances and stretcher carriers, city buses were mobilized for transport of ambulatory patients. The placement arrangements made by the DVAMC staff were not used, and the Paramedic Division of the Denver Department of Health and Hospitals initiated new placement procedures that included the dispersal of patients to 16 different hospitals in the Denver area. The evacuation of patients proceeded in the following order by ward: intensive care units, medical and surgical, and psychiatric. Nursing personnel ensured that each patient was dressed and wrapped in

Martin J. Blaser and Richard T. Ellison III

blankets, and each patient was accompanied by his hospital chart and nursing care plans. The first patients left from the hospital’s front lobby, which served as a staging area at 0100 hours in 15°F (- 9.4”C) (wind chill factor 12°F ( - 11.1 “C)) weather. No accurate tally was kept of which patient went to which hospital. The most seriously ill patients were transported by ambulance, whereas ambulatory and most wheelchair patients were evacuated by city bus. Each bus was staffed by at least one physician and nurse. Because the aisles of the buses were not wide enough to accommodate more than six wheelchairs each, some patients waited outdoors in the subfreezing weather for up to 15 minutes. Despite these problems, the evacuation was orderly and calm. By 0320 hours, all patients had left the hospital. No injuries to patients, hospital employees, or emergency personnel were reported. Interim Activities

4fter the last patient had left, a 0400 hour meeting of all on-hand staff established two major priorities: (1) determining the locations of all patients and ensuring adequacy and continuity of their medical care; and (2) making plans for the reopening of the hospital and the return of the patients. A further priority involved contact with the public, since following extensive news media coverage, there were numerous telephone calls by concerned relatives. A central telephone number with adequate incoming lines was established for answering these questions; this number was broadcast by the media, and telephones were manned by social workers. The news media informed the community that the hospital was closed, and all persons who came to the emergency room were triaged to a neighboring hospital. Salvation Army and Red Cross personnel assisted with these early operations. The location of most evacuees was established within several hours, but not un-

Rapid Hospital Evacuation

til 30 hours later were all accounted for. This occurred because the hospital census for December 15 showed 242 patients, including 13 who had been discharged prior to the evacuation. Not surprisingly, these 13 patients could not be found at any of the receiving hospitals, and only were located when their homes were called. Once the location of patients was established, doctors from the DVAMC went to the receiving hospitals to offer assistance in managing their care. Temporary staff privileges were extended to the DVAMC staff by all receiving hospitals. Three patients receiving chronic hemodialysis were evacuated to a second hospital because the first hospital did not have dialysis facilities. All the psychiatric patients went as a group to a single facility, Fitzsimons Army Medical Center, where their care was provided by the DVAMC psychiatric staff. The status of the physical plant was the determining condition in planning for the reopening of the hospital. The source of the leak was found by approximately 0200 hours on December 16, and the water turned off. By 1600 hours all 500,000 gallons of water had been pumped out. The leak was repaired, the water and steam systems turned back on, suction pumps and motors cleaned, the fire protection system reinstalled, and the drinking water certified as safe. All of these tasks were accomplished by December 19. Based on the interim progress, on December 17 the Hospital Director decided that the hospital would reopen on Wednesday, December 2 1, with all patients to return on that day, and for clinics and elective surgery to begin again on the following day. During the first three days after the evacuation, a skeleton staff maintained the hospital. To prepare for the reopening, the DVAMC doctors visiting their patients at the other hospitals wrote readmission orders that included likely transportation status, diet, nursing and medication orders. These orders, received at the DVAMC, permitted the support services to prepare

389

for the return. On the two days preceding the return, the full hospital staff made preparations.

Return Phase To facilitate the orderly return of patients, each patient was given three color-coded cards with their name, hospital number, and the ward to which they were reassigned. On leaving the recipient hospital, on returning to the front lobby triage area of the DVAMC, and on arrival on the designated ward, a card was handed to an administrative officer. This system allowed for the orderly readmission of patients, and a continuous assessment of their locations. Several factors aided the return process. Whenever possible during the five days at the other hospitals, patients were discharged to their home or to a nursing home. Patients who were in intensive care units were not returned to DVAMC until they were sufficiently well to be on a general ward. Although imperfect (Table l), the knowledge of likely transportation mode simplified scheduling; 86% of patients returned by the anticipated mode. Administrative personnel from DVAMC were present at each of the recipient hospitals to facilitate the checkout procedure and transportation logistics. Each bus was staffed by a physician and nurse with an emergency kit available. At 0800 hours on December 21, the return began. Despite patients coming from 15 different hospitals, and an outdoor temperature ranging from - 15°F (- 26.1 “C) to - 8°F (- 22.2”C) with winds gusting to 13 knots, the return phase went very smoothly. Transports came directly to the front door; no patient was outdoors for more than two minutes. By 1530 hours all 164 evacuees who had not been discharged from the receiving hospitals and were able to be moved had returned to the DVAMC. There were no undue problems during the return. As scheduled, the clinics opened the next day, and elective surgery began on the fol-

Martin

390

Table 1. Expected and Actual Transport Return to the Hospital

J. Blaser and Richard

T. Ellison

Ill

Modes for

Number Actually Arrived by Mode

Mode

Number Expected

Ambulatory

Wheelchair

Stretcher

Ambulatory Wheelchair Stretcher

95 41 28

81 3 0

12 38 3

2 2 25

Total

184

84

51

29

lowing day. Thus by December 23, seven days after the emergency evacuation, the hospital was operating normally.

their return; standard microbiologic tests were done.“,’ We tabulated costs billed to the DVAMC by the 16 receiving hospitals as well as other evacuation related events.

Methods Results To assess mortality associated with the evacuation, the number of fatalities occurring during the six-week period surrounding the evacuation was compared with those occurring during the same time period in the preceding two years, and these numbers compared with the patient census during these periods. In addition, we reviewed the charts of all patients who were evacuated and who died in the subsequent two weeks. To assess morbidity associated with the evacuation, at the time of the return the physician readmitting each patient was asked to complete a questionnaire placed on the patient’s chart. The questionnaire evaluated the patient’s preevacuation condition, the mode of transport during evacuation, the duration of time spent during the evacuation traveling to a new hospital, and adverse effects related to the evacuation. We also reviewed infection control and microbiology laboratory records to determine whether there was an increase in nosocomial infections and resistant organisms during the postevacuation period. To determine possible changes in the gram-negative flora of patients because of the evacuation, unselected medical and surgical evacuees at several nearby recipient hospitals had throat cultures performed while there and after

Nine patients died in the two weeks following the evacuation. By chart review, none of these deaths appeared to be related to the evacuation. The mortality rate for the month after the evacuation was similar to those for the same time period of the two previous years (Table 2). Of the 164 patients who returned to the DVAMC, a questionnaire was completed on 70 (Table 3). Morbidity and complications in delivering medical care related to the evacuation were identified in 21.4% of the returning patients and included delays in needed diagnostic procedures,’ delays in appropriate therapy,5 mood changes,4 medication errors,* and duplication in diagnostic procedures.’ None of these events was severe. No increase in nosocomial infections, specifically including pneumonia, was noted in the postevacuation period as assessed by a review of blood and sputum cultures received by the clinical microbiology laboratory. The antimicrobial susceptibility patterns of aerobic gram-positive cocci and gramnegative rod clinical isolates in December 1983 and January 1984 compared with those seen during the five months prior and two months after the evacuation period were no different nor were any unusually resistant

Rapid

Hospital

Evacuation

391

Table 2. Mortality at the Denver Veterans Administration Medical Center, Selected Time Periods, December 1, 1981, to January 15, 1984 Number of Deaths 1981 December l-l 5 December 16-21 December 22-31 January 1-15 of subsequent

year

4 7 4 14

Total for December 16 to January 15 of subsequent

year

25 (3.4)

1982

(1 .O)’ (4.7) (1.9) (4.7)

7 6 6 8

(1.8) (3.7) (2.6) (2.0)

20 (2.5)

1983 10 5t 4 8

(2.7) (3.9) (2.2) (2.2)

17

(2.5)

‘Rate per 1,000 patient-days. tPeriod of evacuation.

Table 3. Morbidity Associated

Service

Number Patients Returned

with Evacuation Number for Whom Data Available

Percentage With Adverse Effects

Medicine Psychiatry Surgery Neurology

63 35 61 5

30 35 0 5

33.3 14.2 NA 20

Total

164

70

21.4

individual isolates recognized. Throat cultures were performed to detect potential changes in the spectrum of colonizing aerobic gram-negative bacilli on 80 medical and surgical evacuees and then 39 and 20 of them, respectively, one and two weeks after return to the DVAMC. The percentage of positive cultures ranged from 12.5% to 20.0% for the three sampling times, with Klebsiella pneumoniae, Escherichia coli, Serratia marcescens, and Pseudomonas aeruginosa the predominant isolates identified, as they were for all clinical cultures done between July and November 1983 at the DVAMC. The susceptibility patterns for each gram-negative rod species were similar to those seen among the clinical isolates during both the pre- and postevacuation periods. The direct financial cost associated with the evacuation was $766,524. As anticipated, the greatest costs were for the hospitalization of the patients. Dividing the total hospitalization charges ($630,004) by the

969 patient-days yields an average daily cost of $650.16 per patient. We performed a more complete analysis using billings for 851 (87.8%) of the 969 days (Table 4). The costs for hospitalization of psychiatric patients were based on a previously agreed formula with Fitzsimons Army Medical Center, but the costs for the medical and surgical service patients were those actually billed by the 15 other hospitals. Other costs of the evacuation included those for engineering and repairs ($98,568), cleanup ($10,760), transportation ($10,919) and overtime ($15,408).

Discussion Rapid evacuation of hospitalized patients is fraught with difficulties. When our hospital was forced to evacuate, we studied the process to learn which factors were favorable, and how best to plan another such procedure. In general, the evacuation-return

392

Martin J. Blaser and Richard T. Ellison III

Table 4. Per Diem Patient-Care Dollar Costs Associated by Service Status of Patients

with the Evacuation

Service

Number Number Per-diem Per-diem

of patient days of hospitals billing DVAMC dollar costs (range) dollar costs (mean)

Medical

Surgical

Psychiatric

408 15 314-1793 614.23

134 6 380-2593 1500.51

309 1 NA* 327.00

‘Not applicable.

process at the DVAMC was done safely and efficiently, although it was not without difficulties. Among the favorable factors during the evacuation phase were the presence from the outset of the key administrative and nursing personnel who made decisions promptly,* that morale was high,* that there was a surplus of manpower, and that cooperation by all segments of the community was excellent. As previously reported for evacuations in genera1,9 the existence of a well-recognized chain of command facilitated an orderly hospital evacuation. Further, an established command structure enabled volunteer help to be directly integrated into the ongoing activities. Initially, the DVAMC staff arranged to concentrate patients in a few nearby hospitals, facilitating the logistics of their transport, continuing care, and return. However, the priority of the Office of Emergency Preparedness paramedic-activated system was and is to disperse patients so as not to overload any single facility. Although this approach provides optimal care for a disaster requiring the management of a large number of critically ill patients, it may not provide for the best management of medically stable patients who do not require either labor-intensive initial assessment or care, and for whom maintenance of ongoing therapy without complications is the major goal. It now seems clear that whenever possible, a consensus of priorities should be reached before patients are actually moved.“’ Another problem was the inability to locate all patients promptly. Initially employing the card system that was used during the re-

turn phase could have eliminated this problem. In similar situations, the use of multiple cards per patient, each turned in at specific checkpoints, would aid in rapid assessment of the ongoing logistics. An important operation during the interim phase was that medical personnel continued to follow their patients while at the other hospitals. Continuity of care probably minimized morbidity, especially among the psychiatric patients, and enabled physicians to write readmission orders on the day before the return was accomplished. This allowed the nursing, pharmacy, dietary, and housekeeping staffs to prepare for the large influx of ill patients. The discharge to home of recuperating patients* helped lessen the impact on the day of the return, which often is the most chaotic phase of evacuation.9 Although imperfect, prior knowledge of probable modes of transport greatly simplified logistics. Throughout the evacuation period, high staff morale contributed to the smoothness of all operations. Evacuations of noninstitutionalized populations are associated with low injury and death rates.9 After previous relocations of long-term geriatric inpatients, mortality rates increased” or remained constant’*. Although there was no excess mortality associated with this evacuation, some morbidity was present. As has been reported after previous evacuations,2,4,11 some patients had difficulty adapting to the change in environment and underwent significant mood changes. Incapacitating emotional problems are uncommon after natural disasters,13 and our experience supports this

393

Rapid Hospital Evacuation

observation in the setting of hospitalized patients. More common complications of this evacuation were delays in diagnostic and therapeutic procedures. Fortunately, these delays did not influence the eventual outcome of these patients’ illnesses, although they may have lengthened the hospitalizations and contributed to the financial costs of the evacuation. In the absence of appropriate control groups, we do not know whether the rate of these relatively minor problems was greater than that normally occurring among this population. No morbidity was noted after a 16-hour evacuation from a psychiatric hospital,2 but after a twoweek evacuation of patients from a geriatrics hospital, a marked increase in chest infections was noted.“ No such increase was observed in our hospital where nosocomial pneumonias are generally common. In a previous experiment of nature, an identical pattern of nosocomial infections persisted despite the shifting of a hospital population from an old physical plant to a new one.14 In this evacuation, the resiliency of the bacterial flora of hospitalized patients was demonstrated in a different way. Despite the temporary relocation of patients to a wide group of different institutions, no changes in the overall patient-associated microbial flora could be demonstrated by studying either the clinical isolates submitted to the laboratory or the gram-negative rods in the pharyngeal flora of evacuees. In contrast to other hospitals in the Denver area, 98% of the aminoglycoside usage at

the DVAMC is with amikacin. Although gentamicin and tobramycin were widely used at the hospitals at which evacuees were placed, the gram-negative rods isolated from these patients had susceptibility patterns comparable to those of DVAMC isolates during the preceding five months. These data suggest that either there is a relatively uniform bacterial flora of hospitalized patients among the medical institutions in this geographic area, or that five days was insufficient for change of the gram-negative flora. In conclusion, the successful evacuationreturn operation at our hospital emphasizes the need for disaster planning, for a centralized command structure in a crisis, for on-going monitoring of the process, and for attention to continuity of care during relocation. Our data suggest that such evacuations can be undertaken with only minimal morbidity and no mortality. Both patients and their microbial flora appear resilient to change. Such experiments of nature provide the opportunity to study a variety of questions pertinent to patient care.

Acknowledgment-We thank Linda Laxson, RN, Wen-Ian L. Wang, PhD, and Coseen Hongsermeier, BS, for assistance with the microbiologic studies and Larry Seidl, MD, for support and encouragement. This work was supported by the Medical Research Service of the Veterans Administration.

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1979; 107:117-123. 3. Ellen B: Emergency evacuation.

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pital disaster plan: some new solutions to old problems. J Trauma 1982; 22~694-697. 11.Aleksandrowicz DR: Fire and its aftermath on a geriatric ward. BullMenninger Clin l%l; 25:23-32. 12. Borup JH, Gallego DT: Mortality as affected by interinstitutional relocation: update and assessment. Gerontology 1981; 21:8-16.

Martin J. Blaser and Richard T. Ellison Ill

13. Penick EC, Powell BJ, Sieck WA: Mental health problems and natural disaster: Tornado victims. J Comm Psycho1 1976; 4:64-68. 14. Maki DC, Alvarado CJ, Hassemer CA, et al: Relation of the inanimate hospital environment to endemic nosocomial infection. New Engl J Med 1982; 307:1562-1566.