When targeted by disaster, hospitals might need to transfer patients to alternative facilities.Reference Blaser and Elliso 1 , Reference Bagaria, Heggie, Abrahams and Murray 2 Throughout the world, many hospitals and health care facilities can be affected by floods, hurricanes, cyclones, earthquakes, and other natural disasters. In these emergency situations, the physical and functional integrity of health care facilities and hospitals must be maintained. Evacuation of a health care facility is considered the last option.Reference Wise 3 Hospitals are only truly safe from disasters when they are available and functioning with maximum efficiency immediately after the incident.
An investigation of a serious fire that occurred on October 26, 2011, in a psychiatric ward in a Suffolk hospital in the United Kingdom described the outcome. A patient had set the bedding in the room on fire and remained in the room as the fire developed. The closed-circuit television showed that the staff did not respond immediately to the alarm and did not follow the unit's fire emergency plan. Because of the delay, the patient became unresponsive, and the conditions were so poor that staff-assisted evacuation was not possible. Consequently, the patient could not be removed from the smoke-filled room until rescued by firefighters. The patient then spent 2 weeks in critical care for serious smoke inhalation. 4
The Central Arkansas Veterans Healthcare System evacuated seriously mentally ill veterans following hurricanes Katrina and Rita. After the evacuation, the staff noted the ways they could improve how psychiatric evaluations of relocated patients were performed. As circumstances dictated rapid assessment and intervention, it would have been beneficial to focus on the elements of the psychiatric evaluation that are imperative for safe and effective evacuation.Reference McClain, Hamilton, Clothier and McGaugh 5
Health care facilities must have operational plans in place for a full evacuation, including detailed procedures for the transport of patients from the hospital, when an impending disaster presents a significant risk to patients and staff. Two main sources of evacuation risk are the threat risk (reason for the evacuation) and the transportation risk. The transportation risk is a function of the types of patients, the vehicles used for evacuation, and the time required to transport the patients to receiving hospitals.Reference Bish, Agra and Glick 6
A review of 5 London hospital fires and their management described the successful evaluation of hospitals. Evacuation processes were facilitated through excellent pre-planning, staff teamwork, and leadership.Reference Wapling, Heggle, Murray, Bagarta and Philpott 7 Regardless of the outcomes, incident reports and evaluations of evacuation procedures have been important to facilitate the sharing of information with other hospitals and health care facilities that can benefit from the lessons learned.
Events Before The Evacuation
On December 2, 2010, a forest fire erupted on the outskirts of the Druz village Isfiya, and the flames rapidly spread to the Carmel Mountains, near Haifa, Israel. A total of 44 people died in the fire, and many more were wounded. The fire damaged 42000 hectares of forest, burning about 5 million trees. It also demolished 74 buildings and damaged an additional 173. During the fire approximately 17000 residents were evacuated, and 11 emergency centers provided shelter for evacuees.
Fire at the Gates of Tirat Carmel Mental Health Center
Tirat Carmel Mental Health Center (MHC) is located at the foot of the slopes of the Carmel Mountains. The hospital grounds include 120 acres with 10 buildings, administrative offices, therapeutic facilities, and storage areas. The hospital has 228 beds in 7 departments including an adolescent department, a psychogeriatric department, and 4 acute care departments. Each department has closed and opened wards. In addition, a long-term residential treatment department contains 20 beds. Occupancy before the fire was 212 inpatients, and another 16 patients in the long-term residential unit (Table 1).
Distribution of Patients in the Hospital Before the Evacuation
The majority of patients at MHC were acutely ill, but none was in physical restraints before the evacuation. The hospital staff during the evacuation included 3 physicians on duty, 1 head nurse, 28 caregivers (nurses and nurses' aides), 3 kitchen workers, 3 housekeeping employees, 2 guards, and 1 driver.
Initial Preparation For Possible Evacuation
From the beginning of the shift, staff members monitored ongoing reports of the fire on the Carmel Mountains. The atmosphere was tense. At 6:00 pm the hospital director instructed the staff to prepare the patients for transfer. The call for evacuation was received at 7:00 pm. All department heads, physicians, nurses, social workers, psychologists, volunteers, and maintenance personnel arrived at the hospital to assist in the evacuation. The staff maintained a calm environment (Figure 1).
Patients were given time to call family members, who were asked to come and take the patients home, if possible. The lists of patients who could be sent home were prepared based on current mental and physical examinations. All families, parents, and guardians of children and adolescents were informed of the evacuation plan. All departments prepared lists of the names of patients to monitor the evacuation. Patients received their medication ahead of schedule. All departments collected their medications, sedatives, first-aid kits, injections, needles and syringes, and sphygmomanometers and stored them in designated cabinets. All cabinets containing toxic medications were locked.
Evacuation
The majority of patients who were evacuated were acutely ill, with diagnoses such as psychosis, suicidality, dementia, eating disorders, mania, or major depression. Most were mobile and not restricted to their beds. However, some had limited cognitive capacity, disorientation, and impaired judgment that required monitoring and close supervision. All patients were accompanied by staff members and police to safe areas.
Evacuation “Under Fire” at Tirat Carmel Mental Health Center
Head counts were performed as the patients boarded the buses. The children and adolescent patients were separated from the rest of the hospital’s population for transport. At the same time, some families arrived to take their relatives home. For families that were unable to reach the hospital before the evacuation, another meeting point was arranged. The atmosphere before and during the evacuation was generally calm and relaxed. There was a feeling of organization and control, a sense of togetherness, and a professional atmosphere of good cooperation among staff members.
Patients boarded the buses by department. Patients were accompanied on foot by the nursing staff to the boarding areas for the buses. The nursing staff boarded the buses with the patients and remained with them through their admission to the receiving hospitals. Additional nurses' aides provided further support by accompanying patients from the closed wards. A security ring of police officers ensured a quick, secure evacuation (Figure 2).
In addition, the head nurse of the psychogeriatric department who was not on duty during the outbreak of the fire, came to the hospital to accompany the patients during their relocation. Patients who were unable to walk to the buses were taken in wheelchairs. Before leaving the premises, the staff counted the patients and prepared a list of all patients being transferred to receiving hospitals. Patients in the adolescent department who were unable to be temporarily discharged and taken home by their parents were transported on a separate bus with the department staff. Staff remained with the patients until they were successfully relocated.
The evacuation process took place under the threat of a raging fire approaching the boundaries of the hospital. The evacuation, therefore, was crucial and immediate. Even so, it was conducted efficiently (Table 2).
Timeline of the Evacuation from Tirat Carmel Mental Health Center
Discussion
The published literature describing how to implement a disaster plan that involves the transport of an entire psychiatric hospital, including patients, nurses, physicians, and staff, to other facilities is scant. Thus, the knowledge gained from the experience of a successful evacuation can benefit psychiatric professionals and their organizations in establishing or modifying their disaster plans.
Post-Fire Evaluation
After the successful evacuation of the Tirat Carmel MHC, the administration conducted a comprehensive investigation together with a research team to analyze and evaluate the management of the evacuation. The purpose of this investigation was to examine the hospital evacuation process from various aspects and organizational standpoints to draw conclusions, and systematically elicit lessons learned from the incident.
Structured questionnaires were completed by all staff members who participated in the evacuation. The focus of the investigation was on the following: management of the evacuation; process of evacuating the various departments; management of the relocation process in alternative facilities; communication with families of patients; maintaining continuity of care and medical information of relocated patients; and medical and therapeutic aspects of care during the evacuation.
Results of the Evaluation
To improve the level of preparedness for future evacuations, 2 models for hospital evacuation were defined: (1) total arranged evacuation, in which patients are evacuated when the hospital receives an evacuation alert; and (2) urgent evacuation, in which an onsite decision is made to evacuate patients, without receiving an evacuation alert.
The operational logistics of the 2 plans are similar, but their order of operations and priorities differ. During the Carmel Mountain fire, Tirat Carmel MHC operated according to the urgent evacuation model. The challenge of an urgent scenario is to evacuate patients and staff as quickly as possible while ensuring safety and security. During this fire, 228 patients were successfully evacuated from the hospital grounds within 45 minutes. No fatalities or injuries associated with the evacuation occurred.
The 2 phases of a hospital evacuation are (1) the internal evacuation phase, which entails the order in which the hospital is evacuated; and (2) the external evacuation phase, which includes the development of a control component, communication with external officials, and transfer of patients to alternative inpatient facilities.
Six principles of action guide the internal evacuation phase:
1. Keeping the departments organized throughout the evacuation process;
2. Structuring the sequence of actions within the departments to prepare patients for evacuation;
3. Arranging immediate access to transportation to reduce the risk of exposure;
4. Creating an alliance with the security services to ensure control and to strengthen the sense of protection;
5. Maintaining control of patients throughout the evacuation process from departure from the department into the open space and while boarding buses; and
6. Conducting a prompt exit from the departments, boarding evacuation vehicles rapidly, and departing quickly.
Alternative frameworks for evacuation planning should be based on an emergency plan that predetermines potential facilities that are able to receive the evacuated patients. In Israel, the emergency plan must be approved by the Ministry of Health Department of Emergencies and the Mental Health Services. It also must be coordinated among hospitals.
Because an unaccounted for patient during the evacuation process may delay the transfer of patients, keeping track of the number of patients during all stages of the evacuation process is critical. Also critical is effective communication during the evacuation, because efficient time management determines the outcomes. Location of the information center should be predetermined and appropriately equipped. The ongoing communication between the information center and the media plays a significant role during evacuation. Information must be updated regularly to keep the relevant services aware of the status of the patients.
We concluded that hospital evacuation is a medical event with management and security challenges and not vice versa. The basis for decision-making is the medical care of patients once the decision to evacuate is implemented until the patients are admitted to alternate facilities. Thus the evacuation process begins with the immediate exit of the first patient from the department and ends when the last patient is admitted to the receiving facility.
The evacuation of Tirat Carmel MHC began with the decision of the Israeli police force on Thursday, December 2, 2010, at 7:00pm and ended on Friday, December 3, 2010, after all of the patients from the children's department were admitted to the designated hospital at 3:00am.
The inspiration and organizational planning of the staff at Tirat Carmel MHC during the Carmel Mountain fire not only saved lives but may serve as a replicable model for responding to a challenging disaster that requires evacuation of an entire psychiatric hospital.
Recommendations
Although the following recommendations provided here are somewhat specific to the local community in terms of the role of the Israeli Ministry of Health, this approach, however, might parallel health departments or other government facilities in other countries.
1. Yearly drills for coping with disaster situations, with participation of the police force and other community-based emergency services in cooperation with the Ministry of Health Department of Emergencies.
2. Improved communication between hospital directors and the Ministry of Health Department of Emergencies. A designated individual in the Department of Emergencies should serve as the point of contact who communicates with the hospital director and coordinates all medical and logistic operations involved in the evacuation of the hospital.
3. Readily available hotline in the Ministry of Health where families can receive regular updates and to allow improved communication with the public.
4. A database of alternative facilities for patient evacuees, with reference to special populations such as the elderly, children and adolescents, and patients in court-ordered hospitalization who need to be escorted and relocated in settings with appropriate physical facilities.
Acknowledgment
Daniel Ben Shushan provided professional assistance throughout the process of the investigation, analysis, and evaluation of the management of the evacuation, and Rena Kurs assisted with the preparation and proofreading of the manuscript.
