Highlights and Main Points Made by Individual Speakers and Participants1
- Considering surrounding area limitations and augmenting their resources when creating evacuation plans can prevent adverse situations on evacuation routes and meet the demand of travelers. (McClendon)
- Creating an integrated tracking system can improve information sharing and coordination of evacuation planning among the impacted state(s), hosting state(s), and the local receiving jurisdiction. (Blumenstock, Hanfling, Upton)
- Existing trauma system models for patient catchment used in day-today care can assist in patient transfers in a regional disaster. (Ward)
- Integrating the health and medical component into regional intelligence centers already in place can improve information processing and risk assessment in an ongoing emergency. (Osborn)
A regional disaster ushers in the need for tracking large numbers of evacuees and patients, including at-risk, vulnerable populations. When multiple groups have shared access to robust information technology systems with multi-use capabilities, better tracking of evacuees and patients is enabled, as well as increased situational awareness. If the technology is not interoperable, different jurisdictions and different levels of government (i.e., state, regional, or local) are unable to communicate with one another during a disaster in real-time and often lack the awareness of
1This list is the rapporteurs’ summary of the main points made by individual speakers and participants, and does not reflect any consensus among workshop participants.
where patients or evacuees are moving. This chapter discusses lessons learned from evacuations and patient tracking in past regional disasters. The challenges and barriers of coordinated information sharing between private entities is also explored, with possible suggestions for ways around those barriers to better protect patients, families, and efficiency of operations.
Whether focusing on sick hospital patients or the healthy general public, evacuation of residents can be extremely challenging for government agencies in preparation for a known event (e.g., an advancing hurricane), or in response to flooding, power failure, or other unforeseen problems. This can be difficult when just limited to one building or one community, but when scaled up to a regional level, it becomes even more important to have decision support, strong communication among entities, and transparency among systems.
One of the first priorities during a disaster is to make sure that evacuation routes do not become clogged. During Hurricane Rita, Harris County, Texas, which comprises much of the Houston Metropolitan Statistical Area, was right in the path of the storm. Speaker Michael McClendon—director of the Office of Public Health Preparedness of the Harris County Public Health and Environmental Health Services—said that because of the very recent memory of Hurricane Katrina just a few weeks prior, many more people elected to leave Harris County than needed when Hurricane Rita’s path was projected. Evacuees from Harris County flocked to interstate highways all at once, causing mammoth traffic jams. Because of the location of the city of Houston, with the surrounding areas en route to Dallas being very rural, there were few resources for thousands of evacuees (see Figure 2-1). Many motorists desperately needed fuel, water, and food on the road, which were not plentiful even before communities along the highways were stripped bare of provisions.
FIGURE 2-1 Photograph of the highways surrounding Houston ahead of Hurricane Rita’s arrival in 2005.
SOURCE: McClendon presentation, July 24, 2014.
Many local communities exercised their legal authority to shut down interstate exits and instead of evacuating to safe locations, thousands of Harris County residents spent more than 12 hours stranded on the highways. As a result of this experience, McClendon said, the state convened local, state, and federal stakeholders to develop a better evacuation plan. The plan developed a color-coding system to stagger departure times and mapped multiple evacuation zones. The plan also called for prepositioning of fuel, water, and food stations along the highway throughout different communities to meet the demands of thousands of travelers, which would be staffed by the Texas Department of Transportation, with protection from law enforcement. The plan also created supply caches for medical equipment and other important items for first aid. Perhaps most importantly, he said, the plan delineated all responsibilities by sector for each local, city, county, and state agency involved, to minimize confusion about roles.
Information Sharing Across State Lines
McClendon also shared his region’s response activities when receiving evacuees as compared to evacuating the region’s own residents elsewhere. Reliant Park—more commonly known as the Astrodome—in Houston, became the temporary home for more than 26,000 evacuees from New Orleans following Hurricane Katrina. Coordination among
multiple levels and jurisdiction is not uncommon; however, such an event involved multiple layers of communication among local officials in Houston and New Orleans, as well as the regional counties and state of Texas and state of Louisiana officials. At that time in 2005, no integrated system existed to assist with the flow of information from an impacted neighboring state, to the hosting state, to the local receiving jurisdiction, causing conflicting information to reach local personnel in Harris County.
McClendon said they set up their shelters in Reliant Park, and planned for the shelter’s capacity of 11,000 persons. Buses began showing up the next day, and did not stop arriving until they had far more than they were told they would be receiving, and thousands more than they could accommodate. Additionally, there were several unknown factors, such as whether evacuees would have clothing, whether animals would be arriving as well, and most importantly, what the final count of evacuees would be. While not an ideal solution, to at least get some concrete information, the Texas State Department of Public Safety sent spotter helicopters along the interstate to gather correct intelligence about what the county should plan for arriving. While this sufficed at the time, better communication practices both vertically and horizontally throughout a multi-jurisdictional region could help to alleviate confusion and misallocation of resources.
Impacts of Unintegrated Health Information Technology (HIT) Systems
Lori Upton, director of regional preparedness for the SouthEast Texas Regional Advisory Council (SETRAC), spoke about patient evacuation and tracking in the wake of several storms. The current SETRAC framework began in 2001 with tropical storm Allison. It caused extensive flooding in the Houston area, which received 30–40 inches of rain over 5 days. One of the major areas hit was the Texas Medical Center, which houses 162 buildings, including 2 trauma centers, a nursing school, a medical school, and a U.S. Department of Veterans Affairs hospital. The Center has more than 93,000 employees and over 6 million patient visits per year. The flooding from Allison caused evacuation of some 3,000 acute care beds and more than 500 intensive care unit beds in one of the two trauma centers. The affected trauma center was down for 1 month. Consequently, at the request of the emergency medical services (EMS) medical director, the two workforces of the trauma centers were combined so that the region could maintain trauma care. There was no
coordinating entity and the flooding throughout hospitals was massive and widespread. Only one trauma center was able to remain open, and she said they quickly understood a coordinated infrastructure needed to be in place, regardless of whether it was private or state run, as everyone needs to join forces when a disaster happens.
Testing Regional Coordination
Hurricanes Katrina and Rita in 2005 were the first time their regional coordinating entity, the Catastrophic Medical Operations Center (CMOC), was called into service. While there was no formal plan or designation, she said there was a commitment to their medical community. Even with just a rudimentary patient tracking system listing patient’s name, chief complaint, and location, they were able to move more than 1,000 patients to other health care facilities during Hurricane Katrina. However, she noted one of the first drawbacks was that none of the participating hospitals had access to the data. Having the chief complaint listed also gave them added information on potential outbreaks. For example, if many gastrointestinal complaints in one area were found, they could quickly notify public health and begin epidemiological testing and surveillance. As noted previously in McClendon’s Texas experience, Hurricane Rita followed just 2 weeks after Hurricane Katrina, so an opportunity arose for a system improvement. The upgraded system was a computer program called “Where’s Mommy?” that could be accessed on everyone’s desktop. The program’s error rate was 0.08 percent, meaning that only two patients had to be moved out within 24 hours because the receiving facility did not have the capability or capacity to provide proper care for them. Not one patient was lost during the tracking following Hurricane Rita, and 2,400 were moved through CMOC.
Integrated Patient Tracking
Upton’s organization subsequently upgraded their patient evacuation tracking system to software called “EM Track,” so that the state and the region were interoperable. The new system has the ability to take pictures of evacuees and has searchable fields. The program includes information on transport status, nature of complaint, medical record, and disposition. It can attach children’s records to parents’ in order to ensure that families remain united. The new system is seen as a successful means of tracking patients and is integrated with public health and spe-
cial needs. The integrated technology has helped to provide a broader common operating picture, as well as to increase situational awareness throughout the region and interface with the state for complete transparency. Other important lessons described by Upton can be found in Box 2-1.
Richard Serino, former deputy administrator for Federal Emergency Management Agency (FEMA), described his experience regarding information sharing during the Boston Marathon bombings of 2013. Boston’s Medical Intelligence Center (MIC), currently a unique concept, was created in 2009 to coordinate all members of the medical community, including state and local public health, EMS, and city and regional hospitals, and has since grown to include business associations and the private sector in the region. The MIC is also linked to Boston’s law enforcement fusion center, called the Boston Regional Intelligence Center (BRIC),
Important Lessons Learned at the Regional Level
from Hurricanes Katrina and Rita
Lori Upton Presentation
- Adverse impact of prolonged evacuation times—only move patients once if possible.
- Hidden surge capacity within a regional health care community—need to designate receiving facilities, surge facilities, and support facilities.
- Do not evacuate to another coastal community.
- Prioritize evacuations—that is, first focusing on homebound individuals and then coastal facilities.
- Plan for high numbers of homebound and special needs individuals.
- Use brightly colored vests to identify patients while in transit to reduce confusion.
- Stage ambulances—coordinate all ambulances coming from different places to streamline calls and provide shelter and food for the drivers and paramedics and keep them from reaching exhaustion. The year 2005 was the first time it had been done in Texas.
- Repeatedly update the manifest—ensure that if patients are listed as being present they have actually arrived and are physically at the hospital.
which coordinates law enforcement information flow across nine jurisdictions in the metropolitan area. To further ensure this important health connection to law enforcement, the city has a paramedic working full-time in the BRIC who is also responsible for running the MIC. As the entire health care system across the country continues to undergo changes, this type of regional public–private partnership involving health care, public health, and law enforcement could be a model for information coordination during emergencies. Even if a separate intelligence center dedicated to the medical community is not feasible, Osborn of the Mayo Clinic, added that including health expertise into fusion centers could promote better information processing, as well as understanding what risks are immediate and related and should be communicated to the health care sector across communities. Better understanding and communicating the value added in adding a health component to Incident Command System and emergency operations center (EOC) systems already in place could also aid in this transition.
Coordination Through Digital Emergency Operations Centers
Showing how essential good communication and incident management are, Serino highlighted that not one of the Boston area hospitals that received the 260 patients injured in the Boston Marathon bombing was overwhelmed. Although that was also attributable to good relationships and years of planning and practice, being able to monitor needs and status of different hospitals through the region’s Web EOC system and notifying member health care organizations of the bombings within minutes aided in the process of dispatching critical patients across multiple EMS companies safely and successfully. This was seen as a success, and could be a good measure for other regions to test scenarios with their Web EOC systems and member hospitals to evaluate whether the same outcomes might be seen.
As the EOC notifications and patient transports were occurring, incident command also realized the immediate need for additional law enforcement, as all hospitals reported that they were following protocol after a terrorist attack and going into lockdown mode, and many of the now established facts were very uncertain at the time. Because Boston police and Massachusetts state police teams were already committed to
the marathon course, incident management was able to coordinate and rapidly send law enforcement teams from surrounding cities and towns to each hospital under lockdown. While this event quickly involved the Federal Bureau of Investigation (FBI) and other federal agencies that were in charge of many parts of the response, a unified command structure was active, and several decisions were still made locally. He emphasized the importance of holding full-scale exercises, not just tabletops, to find important gaps in operations, and said doing this in Boston in previous years directly resulted in changes to policies that were called into play after the bombings.
Serino also highlighted the utility of social media for real-time information and situational awareness. While at FEMA during Hurricane Irene he was told by regional emergency medical management in New England that residents on the ground in Vermont were faring well enough and did not need support. He simultaneously noticed hundreds of tweets, geo-located pictures, and references to flooding and hurricane-related damage in Vermont. So although official requests were not coming in from state or regional entities, FEMA was able to see immediate needs and start sending resources quickly to the affected communities, thanks to social media.
The uses and benefits of HIT in disasters have increased similarly to the use in routine patient care, but there are still opportunities for improvement. Because of separate funding streams, there are occasional redundancies in tracking systems, and a lack of interoperability due to proprietary or other technological challenges. Similarly, state and local health authorities may have not spent time considering needs on a regional level, so when large-scale evacuations or patient movements occur, there are gaps in systems or transparency is less than optimal. With this in mind, speakers and participants offered several suggestions for improving practices and policies related to evacuation, patient tracking, and information coordination:
- Some participants during this discussion advocated establishing the next generation of an integrated patient, victim, material, and fatality tracking system based on a review of previous events, and integrating the system with electronic health records (EHRs). Several called for an integrated system that can address multiple needs, look at previous events such as Hurricanes Katrina and Sandy for lessons, and reduce redundancies from creating several different siloed systems (i.e., patient tracking, evacuation tracking, medical countermeasure materiel tracking) by multiple agencies and organizations. However, as pointed out throughout this workshop series, simply looking retroactively to past events may not give the full picture for predicting future needs and capabilities. Taking a nimble, dynamic stance when creating new systems could alleviate this issue, as many models in this chapter explored. Vicki Sakata, senior medical advisor at the Northwest Healthcare Response Network, added that the entire spectrum should be included in tracking, from pre-hospital response and care in the field all the way through to acute hospital care and any future movements or transfers until release.
- Several speakers and participants stressed the need for standards-based interoperability of health information systems in addition to just tracking patients in an emergency. While one centralized database for the country is not expected, standards will allow access to and sharing of information across different databases. There are also opportunities for integration between EHRs and application programming interfaces that allow public and private partners to share data (e.g., to connect federal or state emergency preparedness centers with local emergency departments and emergency responders) (IOM, 2014).
- Trauma systems should share lessons learned about key data points to include in a regional disaster registry, to guide a prehospital tracking system, said Jolene Whitney, specialty care program manager at the Bureau of EMS and Preparedness at the Utah State Health Department. This could alleviate problems that arise with multiple tracking systems that are not connected. Integration of patient tracking/pre-hospital systems with hospital and health care EHRs can also improve the care of the patient, said Jennifer Ward, president of the Trauma Center Association of America.
- For patient transfers in a regional disaster, Ward recommended leveraging existing patient catchment systems (e.g., modeled around existing trauma systems) and building on day-to-day care (Lurie et al., 2013). Creating a new system and identifying new players could bring more challenges than simply leveraging the existing daily systems and Memorandums of Understanding that people are familiar with and already understand. However, a robust, daily trauma system is not guaranteed. Ward mentioned federal bills authorizing funding for grant programs supporting trauma system planning, regionalization of emergency care, trauma care centers, and trauma service availability, but monies have not yet been appropriated, and some will need to again be reauthorized before the programs can begin.2 Effective, regional health care systems could assist in a stronger response to infectious diseases like Ebola Virus Disease and other public health emergencies.
- Dan Hanfling, of UPMC Center for Biosecurity, said that emergency planners need to define the “buckets” of information that should be prioritized and used widely to ensure that responders and researchers are capturing the same information with the same terminology. Differences in terminology are hampering information sharing between sector partners.
- Including health expertise into law enforcement fusion centers could promote better information sharing, noted Osborn, as well as understanding what risks are immediate and related and should be communicated to the health care sector across communities. Better understanding and communicating the value of adding a health component to Incident Command System and EOC systems already in place could also aid in this transition.
2See http://www.appropriations.senate.gov/sites/default/files/hearings/Trauma%20Center%20Association%20of%20America.pdf (accessed April 9, 2015).