In the last 2 decades, hospitals have dealt with natural disasters that required emergency evacuation of patients, including critically ill neonates. This vulnerable population, being completely reliant on staff and technology, suffers heavily from compromised care during emergencies. Reference Barfield and Krug1,Reference Chung, Foltin and Schonfeld2 As a result of this, their emergent evacuation is a high-risk activity for which planning and practicing is imperative. Understanding this, the Centers for Medicare and Medicaid Services (CMS) in 2016 established national emergency preparedness requirements to ensure adequate planning for disasters and coordination with federal, regional, and local emergency systems. 3 The Joint Commission (TJC) also issued specific requirements for emergency management and preparedness, known as Standards of Care for Disaster Preparedness and Response. 4 Hospitals are mandated to have a disaster management program, the Emergency Operations Plan (EOP), that addresses emergency preparedness and planning activities. It requires periodic actual or simulated testing of the EOP, including evacuation. 4
Most literature discussing evacuation challenges and disaster management is focused on the adult population. Most of the neonatal evacuation literature has stemmed from evacuations for hurricanes. Evacuation of a level 3 NICU during Hurricane Katrina taught the importance of teamwork, charged battery-operated equipment, ensuring patient identification, pre-prepared hospital transfer summaries, and creative solutions to move patients when normal egress routes were blocked. Reference Bernard and Mathews5 Lack of technology during power failure prompted staff to rely on observation and assessment skills and alternate methods for thermoregulation for the smallest neonates. Reference Orlando, Bernard and Mathews6 Hurricane Ike forced NICU personnel to make use of alternate water sources, Reference Mitchell, Anderle and Nastally7 and Hurricane Sandy taught a level 3 NICU the importance of a clear command structure, having backup medical records, personnel, and equipment, and having a flexible plan during its evacuation of 19 infants. Reference Espiritu, Patil and Cruz8
Other natural disasters have necessitated the evacuation of critically ill infants, including the 2016 Kunamoto earthquakes in Japan, which again required making do with limited technology, and displayed the importance of maintenance of thermoregulation for neonates. Also highlighted was a lack of regional coordination to assist in transfer of neonates to other facilities. Reference Iwata, Kawase, Iwai and Wada9 A study of challenges and advantages encountered by staff in NICU evacuations during the 2018 California wildfires stressed the importance of evacuation equipment, creativity with resources such as the use of car seats as transporters for stable infants, command structure, interhospital communication, and the impact of smoke on air quality. Most importantly, a significant portion of surveyed participants noted a need for practice prior to these types of events in order to improve performance during a real evacuation. Reference Ma, Cohen and Lee10
In 2012, a NICU in El Paso, Texas, experienced a fire with subsequent electrical failure that prompted a planned, full-scale evacuation of the entire hospital. Fire fighters were readily available during this event, and it was noted during debriefing that staff heavily relied on them for evacuation. Hence, the NICU did not have to notify internal command and the public of an evacuation, used little evacuation equipment, did not coordinate vertical patient evacuation, did not determine the evacuation route, did not identify ongoing care needs emergently, and relied on firefighters to prioritize patient and staff safety, among other tasks. This occurred despite the NICU staff regularly fulfilling CMS and TJC requirements for emergency preparedness.
As is evidenced by all these events, evacuation of critically ill neonates requires careful preparation, as well as the existence of a NICU emergency response plan which should be based on the most current literature including published neonatal evacuation toolkits. Reference Farra, Miller and Gneuhs11–Reference Lin, Taylor and Cohen14 It also necessitates that providers for neonates work within the greater context of disaster preparedness in hospitals, cities, and regions. Reference Barfield and Krug1 Unless education on NICU emergency management is provided upon hire to the hospital and as regular training, NICU personnel may not be clear as to their expected responsibilities in emergency neonatal evacuation. Reference Schultz, Pouletsos and Combs12
There is literature supporting the use of evacuation simulations to improve staff competency in disaster preparedness for neonatal intensive care units. Reference Farra, Miller and Gneuhs11,Reference Lynch, Kugler and Niedziela15–Reference Gray, Thomas, Burns and Umoren18 To our knowledge, however, there is no literature describing evacuation simulation for NICUs on a citywide scale that includes actual response by community first responders. Here, we evaluate an evacuation exercise occurring across 6 NICUs in El Paso, Texas, utilizing firefighters and ambulance providers. The purpose of this simulation was multi-fold: to test the effectiveness of hospital-specific evacuation processes in each NICU, to evaluate NICU personnel’s knowledge and competency in these, and to familiarize first responders with this specialized patient population. This was accomplished by assessing staff reactions to the simulation with post-exercise surveys, evaluating areas of strength and areas for improvement in each unit’s evacuation response with a standardized assessment tool, and requesting first responder feedback. The eventual goal was to incorporate generalizable NICU-specific guidelines from these lessons learned to improve each hospital’s internal processes as well as to incorporate them into a comprehensive citywide hospital disaster management plan.
Methods
This simulation included evacuation exercises at each of 6 Level II-Level IV neonatal intensive care units from different hospitals in El Paso, Texas. Out of these, 1 of these hospitals was a free-standing children’s hospital with 50 NICU beds. The rest were general hospitals with a NICU, ranging from 6 to 35 beds. Each NICU had to respond to a simulated electrical fire in the neonatal intensive care unit itself and vertically evacuate 6 simulated patients of varying acuity into awaiting ambulances in the hospital parking lot with intent to transfer to another facility. This was undertaken over 6 months and was facilitated by the Border Regional Advisory Council (RAC) in concert with staff from each NICU after a need was identified from the 2012 real life evacuation in one of the NICUs.
The Border RAC is a healthcare coalition charged with developing and implementing an inclusive trauma and emergency health system, 19 for El Paso and other surrounding counties. The City of El Paso is located in El Paso County, a county on the Texas-Mexico border which is large in terms of area (approximately 1012 square miles) and population (839238). 20 Members of the Border RAC Perinatal Subcommittee met with representatives from each NICU’s management, nursing staff, medical staff, hospital safety office, the El Paso Fire Department (EPFD), and local emergency medical service representatives in a series of planning meetings prior to the actual simulations.
On each NICU’s simulation day, after a pre-exercise briefing, the simulated fire was discovered within each NICU with staff having to initiate emergency procedures and vertically evacuate the area to an awaiting ambulance in the hospital parking lot. Elevators could not be used. Evacuated simulated patients included 1 of the highest acuity (intubated, mechanically ventilated, and on multiple continuous intravenous infusions), 2 of medium-acuity (on oxygen and intravenous infusion), and 3 low-acuity patients (on gavage feedings). The evacuation exercise included actual response from the EPFD and ambulance services. Although all personnel had annual, passive, hospital-specific emergency operations training mandated by CMS and TJC, staff from only 1 of these NICUs had previously participated in an actual evacuation. There were about 30 participants in each simulation. These comprised of nurses, respiratory therapists, and neonatologists. Though planned participants did sign in, many more came to help during the exercise, thus making identifying actual participants challenging.
The core facility capabilities and emergency response objectives tested are listed in Table 1. These were based on objectives for hospitals and other agencies developed by the Federal departments of Health and Human Services, and Homeland Security, 21–23 and tailored to opportunities identified during the previous actual fire-related evacuation. Completion of these objectives was evaluated by each hospital’s Hospital Safety Officer and Border RAC staff using a standardized tool across all NICUs, based on exercise evaluation guidelines from the Homeland Security Exercise and Evaluation program (HSEEP)(Supplement 1). 23 The same Border RAC staff provided some ‘interrater reliability’ as they were present for each NICU’s evacuation simulation. EPFD participants were also asked to provide open-ended feedback on the utility of the simulations and NICU staff performance.
Table 1. Core capabilities and emergency response objectives for each neonatal intensive care unit evacuation exercise
NICU staff were subsequently given a post-simulation evaluation (Figure 1), assessing overall exercise design using an 8-question, Likert scale questionnaire. Likert scales ranged from 1 (Strongly Disagree) to 5 (Strongly Agree). The post-simulation evaluation also provided an opportunity to list strengths noted during this exercise as well as areas for improvement. Data from these evaluations was organized thematically to provide a summary of staff responses to the utility of this city-wide NICU evacuation exercise and over-arching lessons learned from it. This study was exempt from Institutional Review Board Review under Texas Tech University Health Sciences Center EL Paso requirement 45 CFR Part 46 Subpart B, Section 1-2i.
Figure 1. NICU evacuation exercise participant evaluation.
Analysis
Data were analyzed using SAS 9.4 software (SAS Institute, Inc., Cary, North Carolina). A median response value for each question on the 8-item Likert scale post-exercise questionnaire was calculated, along with interquartile ranges, for all 6 of the NICUs combined. Medians were presented with 95% distribution-free confidence intervals. When a NICU staff group chose 2 adjacent categories equally (e.g., 4 and 5), the average values of the 2 consecutive numbers were used in the analysis.
Staff responses to free text questions about strengths of each unit performing the evacuation, areas for improvement, and recommendations for future simulations were categorized into common thematic areas and summarized by frequency. Independent evaluator (Hospital Safety Officer and Border RAC evaluators) and EPFD responses were also collected and categorized by frequency of areas where NICU staff performed tasks with major challenges or were unable to perform them.
Results
Staff reaction and evaluation
Median values for staff responses to Likert questions regarding the design of the evacuation exercise are listed in Table 2. In general, staff at all the NICUs felt very positively (unanimously choosing ‘strongly agree’) about their involvement in the exercise, improvement in their understanding and familiarity of resources, and better preparedness to deal with a similar scenario.
Table 2. Summary of the responses to Part II (Exercise Design) questions from the 6 NICUs*
* Data are from Likert scales that ranged from 1 (Strongly Disagree) to 5 (Strongly Agree). When a NICU chose 2 adjacent categories (e.g., 4 and 5), the average values of the 2 consecutive numbers were used in the analyses.
† IQR=interquartile range.
There were several general themes common to staff responses on strengths noted in each facility during the simulation (Table 3). NICU staff’s knowledge and utilization of transport equipment, including evacuation vests and transporters/ sleds as well as intravenous infusion pumps and ventilator equipment, and their ready availability, were seen as major strengths in all the units. Rapid notification of the operator with requests for help and quick response from other departments, including security and engineering, were also seen as very positive. Other recurring themes were strong leadership and good teamwork. Useful strategies included headcounts for patients, keeping identifiers with patients, and use of other care areas such as the post-anesthesia recovery area (PACU) to serve as rally points
Table 3. Selected themes from NICU staff identified from the participant evaluations
* Out of 6 NICUs
A major area for improvement was a lack of understanding of, and communication with the hospital incident command structure by staff, as well as poor communication with first responders. Another weakness was the lack of equipment (such as incubators) for the resumption of care at rally points, such as the PACU or ER (Table 3). Difficulty with alternate resources and evacuation routes, such as if 1 exit route was blocked or if the location of evacuation equipment was inaccessible, were other common themes. Though the staff performed very well at patient tracking, less attention was paid to headcounts for staff and visitors (Table 3). In a few of the units, there were also problems with staff re-entering the fire area to retrieve additional equipment prior to transfer (Table 3) and difficulty with maintaining appropriate thermoregulation for the patients. Most importantly, staff in every unit commented that doing more drills of this nature would be beneficial (Table 3), with nurses in 2 different units stating, ‘We need more drills with Border RAC and EPFD throughout the year.’
Independent evaluator assessments
The timed objectives were completed in the majority of NICUs. Notification of fire within 5 minutes was performed without challenges in 83% (5 out of 6) of the NICUs. Establishment of a hospital incident command within 10 minutes was performed without challenges in 67% (4 of 6) of the NICUs. Triage and initiation of evacuation within 10 minutes was performed without challenges in 67% (4 of 6) of the NICUs.
Areas where staff performed with major challenges or were unable to perform as assessed by hospital safety officers and Border RAC staff were also similar across all 6 NICUs (Table 4). All the NICUs had difficulties with appropriate labeling and storage of medication for evacuation. Similarly, many did not pack an adequate supply of formulas, diapers, wipes, intravenous tubing and solutions, etc. for a real evacuation situation, which in this scenario was enough to provide continuing care during evacuation/in staging location, and for ambulance transport to get to another facility. Other common themes included lack of assessment for and attention to staff/families who may have been injured in the scenario, and lack of coordination with agencies who could assist with supply needs. All hospitals had challenges with notification to the public about the emergency.
Table 4. Selected tasks performed with major challenges or unable to be performed by NICU staff on independent evaluator assessments
* Out of 6 NICUs
El-Paso fire department’s comments
EPFD participant responses were similar to independent evaluator and staff comments. Solid teamwork and the ability of the NICU staff to start evacuation before EPFD arrival was seen as a strength. They were similarly impressed by staff knowledge of patient needs and use of evacuation equipment. Areas for improvement included lack of organization and communication within the incident command structure, with EPFD members noting a need for an assigned liaison to improve communication flow to first responders and a need for more clearly defined roles for staff. They also reiterated the need for knowledge of alternate evacuation routes and alternate equipment storage locations when certain areas were blocked. Resuscitation equipment located at each exit and being able to perform full resuscitation and resume care in a mobile setting were additionally listed by EPFD as areas of need.
EPFD participants also shared insights specific to their roles as first responders. These included practical areas for improvement such as walking briskly, not running, while carrying patients and the use of ‘spotters’ for staff carrying patients in stairwells as well as assigning a staff member to the exit of each stairwell to ensure all staff, EPFD, and patients had evacuated. They also expressed that staff were unrealistic about the ramifications of smoke exposure which would have impacted order of patient evacuation and reentry into certain areas once evacuated. For example, they commented that staff spent too much time trying to evacuate the sickest patients first, when, intubated patients would have been more protected from smoke exposure, and more emphasis should have been placed on rapid evacuation of multiple lower acuity patients. They noted that this limited evacuation scenario would have been much more difficult if they had to evacuate the whole unit. Finally, many EPFD participants had never seen a premature infant before. They expressed a need for future simulation scenarios such as this 1 to strengthen first responder knowledge of the specialized needs of this patient population and to engender trust between NICU staff and first responders.
Limitations
This exercise was valuable to both NICU staff, who had little practical evacuation experience, and to first responders, who had little experience with this specialized patient population. However, the simulation and its assessment did have some limitations. Since the fire was a simulated threat, it was hard for the NICU staff to imagine and respond to its implications, particularly to understand the ramifications of smoke exposure. The simulation also only involved a few simulated patients, when a real situation may very well be much more complex, calling for a full-scale evacuation of all admitted NICU patients and their families with transport to other facilities. Finally, though NICU staff, hospital safety officers, and Border RAC staff observers had more objective evaluation rubrics, firefighters were asked for their unstructured comments verbally which made their responses more difficult to organize and evaluate.
Discussion
As with other published evacuation training, Reference Gray, Thomas, Burns and Umoren18,Reference Gray, Thomas, Burns and Umoren24–Reference Zell, Blake and Brittingham26 staff from all of the 6 NICUs in El Paso responded positively to simulation of evacuation, feeling that this exercise improved their knowledge of the strategies and resources needed for an evacuation of neonates. In every unit, they desired more practice for emergency situations in order to be more prepared should the ‘real thing’ ever occur. Despite some challenges with plausibility, the success of this simulation adds to the current data that simulation is an effective way for hospitals to bolster staff knowledge in emergency preparedness. Reference Gray, Thomas, Burns and Umoren18,Reference Zell, Blake and Brittingham26 Advanced nursing and respiratory therapist training should indeed include continued education on emergency communication and decision-making, Reference Gray, Thomas, Burns and Umoren24 and the lessons learned in this evacuation simulation speak to the importance of actual practice for emergency scenarios to meet TJC and CMS standards for hospital disaster preparedness, rather than having personnel complete passive training on the topic.
NICUs and first responders in El Paso were able to identify common strengths across the participating facilities. In general, they were able to make a fire notification, set up an incident command, and initiate evacuation in a timely way. Staff knowledge of evacuation equipment specific to neonates, such as evacuation vests and infant med sleds, was very good. This has been supported in the literature as crucial to rapid evacuation. Reference Ma, Cohen and Lee10,Reference Lynch, Kugler and Niedziela15 El Paso’s NICUs also felt they had good teamwork and rapid utilization of assistance from other departments, both of which have been used advantageously in other real NICU evacuations. Reference Espiritu, Patil and Cruz8,Reference Ma, Cohen and Lee10,Reference Cocanour, Allen and Mazabob27 Patient tracking using a back-up system for documentation and identification, and the use of rally points were other strengths common to El Paso units which are also strongly supported in the literature. Reference Bernard and Mathews5,Reference Ma, Cohen and Lee10,Reference Eskandar-Afshari, Carbine, Cohen, Cui, Dueñas and Lee13,Reference Zell, Blake and Brittingham26 A person could speculate that although almost none of these staff had been through an actual evacuation or drill before, they utilized strategies learned in passive training, or that had been successful in other patient care scenarios, such as the use of backup documentation during electronic medical record downtime, familiarity with equipment for patient transport situations, use of other available personnel in low staffing situations, and internal leadership and communication for other unanticipated scenarios such as codes.
Areas in which each of the units struggled were more specific to actual evacuation. The inability to resume full care because of a lack of full equipment when arriving at other staging areas was a common theme. Unlike a transport for imaging, having no incubators available without another way to maintain temperature long term, and not having a full complement of necessary care and resuscitation supplies (diapers, formula, etc.), is untenable for actual evacuation. Indeed, in actual evacuation situations, NICU personnel have had to come up with some creative solutions for thermoregulation and transportation for neonates. Reference Bernard and Mathews5,Reference Orlando, Bernard and Mathews6,Reference Iwata, Kawase, Iwai and Wada9,Reference Ma, Cohen and Lee10 As noted by both staff and firefighters, staff also struggled with finding alternate routes when their typical routes were blocked due to the emergency. These kinds of experiences call for flexibility in planning and creating new alternatives if necessary, something that has also been encountered in actual evacuation scenarios, with NICU staff in 1 hospital in New Orleans even drilling a hole in the wall to create new access when a typical evacuation route was flooded during Katrina. Reference Bernard and Mathews5 First responders also commented that staff struggled with the ramifications of smoke exposure and how it impacted the order of evacuation and reentry into previously evacuated areas which has been echoed in real life fire evacuations. Reference Ma, Cohen and Lee10 Staff often felt they did not have a clear understanding of the hospital-wide incident command structure and their role within that. This was also supported by firefighter comments which stressed the need for improvement in coordination with first responders. Along that vein, like published experience in actual disasters, Reference Bernard and Mathews5,Reference Orlando, Bernard and Mathews6,Reference Iwata, Kawase, Iwai and Wada9 there was little in the way of communication with outside facilities and the public. Some of the latter, along with lack of a search for injuries and reentry into the fire area, may have been due in part to the artificiality of the exercise.
Concepts specific to the evacuation of neonates (compared to adults) were important in this limited scenario. For example, the complete reliance of the patient on the care provider and equipment, the inability of the patients to identify themselves, and the ability to simultaneously transport multiple patients by 1 provider were fully taken into account by staff members at all of the hospitals. These are all concepts with which they were familiar on a day-to-day basis. These facets of neonatal care, however, were foreign to EPFD participants who responded to the simulations, many of whom were surprised at the small size and complex needs of the patients. Need for external thermoregulation, though typically understood by staff in NICUs, became more challenging in the setting of evacuation to the outside, a problem also encountered in actual evacuation scenarios. Reference Espiritu, Patil and Cruz8,Reference Iwata, Kawase, Iwai and Wada9 There was other neonate-specific situational awareness that was lacking though, such as communication with the obstetric department about maintaining availability to attend high-risk deliveries or diverting high risk mothers elsewhere. Reference Espiritu, Patil and Cruz8,Reference Iwata, Kawase, Iwai and Wada9
This multidisciplinary, simulated exercise tested the hospital staff’s annual training required by regulatory agencies. This previous training likely accounted for the knowledge of evacuation equipment, evacuation route, and system for patient tracking. However, it showed that passive training does not consider equipment needs for post-evacuation care, alternative evacuation routes, understanding of incident command structure, and unified communication with first responders, the public, and other facilities. This simulation helped strengthen NICU staff knowledge and comfort with disaster preparedness in their respective units and helped augment each hospital’s EOP with specific attention to the needs of a very vulnerable patient population: critically ill neonates. It identified common strengths and weaknesses surrounding neonatal evacuation that can be used as lessons for the future in the framework of each hospital’s evacuation process, as well as in El Paso’s emergency response planning, including introducing first responders to this special population of patients.
However, what remains untried in a city like El Paso that experiences little in the way of natural disasters or severe weather events, is a real mass evacuation event. El Paso hospitals have experienced and handled a mass casualty event in the wake of the August 3, 2019 shootings where patients had to be triaged to the appropriate hospital, Reference Soto, Chheda and Soto28 and more recently, during the 2020 COVID-19 Pandemic when hospitals were overwhelmed and had to transport patients out of the city for various medical needs, but a mass evacuation affecting the pediatric and neonatal population has never been forced. Local and regional medical emergency authorities in the area, in conjunction with the Texas Emergency Medical Task Force, Reference Epley29 are set up to coordinate regional response capabilities but have not been tested for mass hospital evacuation, unlike those in South East Texas who have responded to multiple hurricanes. Reference Flynn30 It may be very beneficial to regional disaster planning for future exercises to include evacuation of multiple departments within a facility where the total focus is not only the NICU. Simulated mass evacuation from multiple hospitals with need for coordination with local first responders, as well as local and regional emergency medical authorities, including simulated briefs to the public and communication about transfer of care with accepting facilities may be a beneficial test of the system.
Conclusion
Simulation for neonatal evacuation improved NICU staff knowledge of, and comfort in emergency preparedness across multiple NICUs in a city-wide evacuation exercise and was the only 1 of its kind to include actual response from first responders. This aspect highlighted the need for first responders to continue to be exposed to specialized patients like critically ill neonates, and the need for continued simulations to build trust and mutual sharing of expertise between first responders and NICU personnel. Although all hospitals are mandated to have an emergency operations plan and to provide staff education on it, this exercise proved that a multidisciplinary simulation can provide much more robust ‘real life’ experience that is more beneficial to all invested parties than simple knowledge checklists or online trainings. This simulation additionally provided important lessons for NICUs regarding need for improvement in the ability to resume full care during evacuation and transport, need for improved understanding of hospital incident command structure, and need for improved communication with outside agencies, resources, and the public. These themes can be used to improve education, and planning, for disaster preparedness from both a hospital as well as a city-wide level. Future directions could include a simulated mass evacuation from multiple hospitals to include regional emergency response authorities to identify opportunities for improvement in the whole system.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/dmp.2022.158
Acknowledgements
The authors thank the Border RAC for their role in the planning and execution of these simulations as well as in coordinating the El Paso Fire Department and local ambulance response. Additionally, we are grateful to the El Paso Fire Department for its participation in these simulations. We are also grateful to the hospital emergency response officers and staff of the 6 El Paso NICUs that participated in this study and gave valuable feedback.
