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CHEST Journal

1a. We suggest local and regional mutual-aid agreements should be established with other appropriately staffed and resourced hospitals to redistribute critically ill and injured patients from an evacuating hospital(s), and these agreements should be integrated within the framework of disaster preparedness plans. 1b. We suggest creation of predisaster formal agreements between hospitals and transport agencies or between Health Coalitions or Regional Health Authorities and transport agencies for air or ground transport of critically ill patients during a disaster. 2a. We suggest staffing requirements within disaster plans should take into account the staffing resources necessary for desired surge capability to both safely move patients and to provide continuous care for patients remaining in the ICU. 2b. We suggest developing a detailed vertical evacuation plan using stairs when applicable for critically ill and injured patients. 2c. We suggest hospital exercises should simulate a mass critical care event and include vertical evacuation when applicable that evaluates (1) patient movement using specialized evacuation equipment and (2) the ability to maintain effective respiratory and hemodynamic support while moving down stairs. 3a. We suggest specialized care is resource intensive, and specialized ground and aeromedical teams may be required to ensure appropriate initial and ongoing care prior to and during evacuation. 3b. We suggest preidentifying unique transport resources that are required for movement of specific populations, such as critically ill neonates, children, and technology-dependent patients, at a regional level. This information can then be used in real time to match allocated resources to patients. 3c. We suggest conducting detailed and realistic exercises that require ICU evacuation with local and regional ground and air transport agencies. 4a. We suggest the Incident Management System at the evacuating ICU hospital should support early and frequent communication between Incident Command and a designated Critical Care Team Leader (CCTL) during an impending evacuation to provide close coordination and support of ICU evacuation preparations. 4b. We suggest the CCTL coordinating the critical care evacuation should be responsible for (1) categorizing ICU patients by ICU resource requirement and (2) communicating these ICU patient resource requirements with the Hospital Incident Command and to any Regional or National Emergency Command Center supporting hospital evacuation. 4c. We suggest when preparing for and during an ICU evacuation, a primary role of the CCTL should be to categorize each candidate ICU patient evacuee by (1) ICU resources required and (2) skill set of transport staff required. 4d. We suggest CCTLs and staff should receive special training, education, and practice on patient categorization and transport requirements. 4e. Expert providers from evacuation teams and outside facilities, when possible through face-to-face communication on site, can help ensure appropriate transport planning and distribution based on available resources during transport and in receiving facilities. 5a. If pre-event hospital evacuation of critically ill patients might be required, then we suggest planning for patient evacuation or shelter in place using an Incident Command System should begin as early as possible. Possible strategies include shelter in place, partial evacuation, or early evacuation, depending on the circumstances. 5b. We suggest Hospital Incident Command during a threatened hospital evacuation should have a clear and direct mechanism for communication with local governing bodies that control the timing and issuance of regional evacuation orders. To prevent obstruction of ground medical transport during hospital evacuation, coordination with local government regarding timing of recommendations for evacuation of the general population may be required. Efficient ground medical transport of patients during a hospital evacuation may be facilitated by providing a time period for hospital evacuation prior to recommendations for evacuation of the general population. 6a. We suggest during a disaster or pandemic that overwhelms local and regional resources and requires large-scale hospital evacuations assistance, from national and/or international government medical support and evacuation agencies should be requested. 6b. We suggest the CCTL should be aware of the process for requesting evacuation assistance and the resources available at a regional and national level. 7a. We suggest surge ventilators with flexible electrical power and oxygen requirements should be available to support patients with respiratory failure that can maintain function while either (1) sheltering in place or (2) evacuating to an outside facility. These ventilators should be portable, run on alternating current power with battery backup, and have the ability to run on low-flow oxygen without a high-pressure gas source. Surge ventilators may be of limited capability but should be able to ventilate and oxygenate patients with acute lung injury or ARDS as well as airflow obstruction. This requires capability to deliver a high minute ventilation, high flow, and high positive end-expiratory pressure. They should be safe (disconnect alarm) and relatively easy for staff to operate. 7b. We suggest availability of adequate portable energy and medical gas flexible ventilators that can provide accurate small tidal volumes or pressure limits for the premature and neonatal patients expected at designated hospitals (for instance pediatric centers or hospitals with a neonatal ICU). Special consideration should be given to creating a standard, quickly accessible regional stockpile of mechanical ventilators for evacuation of neonatal patients as it may not be feasible for some nonpediatric centers to have adequate numbers of portable energy and gas flexible neonatal ventilators. 8. We suggest evacuation order and identification of appropriate facility should be based on the following factors: 8a. In a time-limited evacuation, less critical patients can be evacuated faster and with fewer resources per patient and, thus, may be moved first in order to evacuate the most patients in the fastest time. 8b. When there is adequate time for evacuation, then more critically ill patients may be moved first and in parallel with less ill patients. Similar acuity patients often use similar transport resources and strain the same group of sending staff members. Thus, moving both the less critical and more critical patients simultaneously in parallel, as compared with sequentially in series (when there is adequate time to evacuate the entire hospital), may decrease the overall time to evacuation. 8c. In some situations, moving groups of similar-type patients to a single hospital entity may enable the sending hospital to provide staff to a single location to facilitate continuity of care and allow receiving hospitals to preplan to surge for specific types of patients and cluster disaster resources. 8d. The most critically ill patients dependent on mechanical devices for life support may, in some conditions, be safely cared for with a shelter-in-place strategy if it is deemed the risk of evacuation is too high. 9a. We suggest during isolated, small, or pre-event ICU evacuations, CCTLs should coordinate with Hospital Incident Command and identify receiving hospitals for patient evacuation via the usual practice of provider-to-provider communication. 9b. We suggest during multiple-facility, large, or late ICU evacuations, the usual provider-to-provider system of communication for identification of receiving facilities should be augmented by other Regional or National Incident Management Systems. 9b.i. Every hospital should be specifically affiliated with (and drill evacuation with) a Regional or National Command Center for such events. Regional or National Command Centers may need to assume responsibility for designation of the receiving facilities for their patients. 9b.ii. We suggest when a Regional or National Emergency Command Center assumes responsibility for patient distribution, they should be responsible for identifying receiving facilities that match ICU patient resource requirements. 9b.iii. We suggest the Regional or National Emergency Command Center should enlist assistance of regional specialist experts to assist in the above matching process for distribution of patients requiring highly specialized care among receiving centers. 9c. We suggest assignment of transportation resources and lines of critical care patient evacuation should follow common existing referral patterns provided receiving facilities retain adequate capacity to care for these patients. 9d. We suggest patients who require advanced specialty care should be directed to high-volume centers and distribution take into account the capacity and resources required to provide ongoing care to these patients. 10a. We suggest standardized preparation of critically ill patients should be performed prior to hospital-to-hospital transfer, including initial stabilization, diagnostic procedures, damage control procedures, and medical interventions, to address anticipated physiologic changes during transport. 10b. We suggest the transport team should provide the equipment used for transport to ensure compatibility and familiarity during transport and retain important resources at the source institution for ongoing care of the remaining patients. 10c. We suggest evacuation planning and coordination should include the provision of additional expert providers, staff, and equipment to assist in the ongoing provision of care in situations where patient volume, acuity, or nature of illness or injury exceeds the capabilities of the CCTL and staff. 10d. We suggest utilizing a staging area for patients prepared and awaiting transport. This area should ideally be located near the point of embarkation and be staffed by medical personnel with training and experience in critical care evacuation. These personnel should be prepared to provide triage and perform ongoing medical care interventions prior to transport. The area should have the capability for additional surgical and medical stabilization pretransport if necessary. 11a. We suggest electronic transfer of patient information to the receiving hospital is optimal because a complete medical record can be included. Electronic transfer may be through an intranet or by copying patient information onto a USB flash memory drive or compact disk and transferring the information with the patient (see the “Business and Continuity of Operations” article in this consensus statement). 11b. We suggest a paper medical record be required to travel with the patient because there may be no ability to send an electronic copy of the medical record, or the receiving facility may not be able to read the electronic format of the medical record. A backup paper system may require (a) a printed copy of the electronic medical record or (b) a handwritten patient identification on a standardized patient tracking form. Any paper system should include basic patient identification, problem lists, and medications on forms that travel with the patient. 12a. We suggest transportation methods should prioritize moving the greatest number of patients as rapidly and safely as possible to locations with adequate capacity and expertise where definitive care can be provided. 12b. We suggest local evacuation of highest acuity patients to hospitals with additional capacity by ground or rotary transport may be most appropriate to minimize risk and reduce ongoing critical care demands at the incident facility. 12c. We suggest alteration in the usual standards for modes of transport may be required during a disaster where transport resources are overwhelmed and evacuation and transport of critically ill patients to a receiving hospital ICU is required. 13a. We suggest tracking of patients should commence in the sending clinical unit, continue to the point of embarkation, and if possible, continue to the destination facility. Tracking of the patient and equipment should commence prior to being loaded onto the transportation. Minimum data sets for tracking should include the patient first and last name, date of birth, medical record number or tracking number or triage number, time leaving facility, transportation company name and transport vehicle number, and expected destination and next of kin. 13b. We suggest both the evacuating and receiving hospitals should track patients and equipment. 13c. We suggest tracking systems may be electronic or paper. In the event of complete power failure, however, a redundant paper system for tracking of patients and equipment should be performed by both sending and receiving hospitals, with communications provided to the sending hospital and/or a centralized coordinating center to confirm receipt of the patients. 13d. We suggest evacuation drills should test tracking of patients and equipment both by electronic and paper systems.

Evacuation of the ICU