Also important to consider, said Dr. King, is that neonatal and pediatric ICUs have different evacuation needs from adult ones. "Regions should consider stockpiling neonatal transport ventilators and circuits," she said. "They should also consider designating pediatric disaster receiving hospitals, similar to burn disaster receiving hospitals."
Ethical considerations
At Bellevue, Dr. Evans said the hospital’s leadership planned patient triage according to influenza pandemic guidelines issued by the provincial government of Ontario, Canada, and the New York State Taskforce on Life and the Law guidelines for ventilator allocation during a public health disaster.
"We knew that if the disaster went very badly, we would be met with much criticism," said Dr. Evans, who joked that she was up nights worried about seeing her name skewered in local headlines: "I kept wondering, ‘What rhymes with Evans?’ "
Using the two sets of guidelines, both heavily oriented toward allocating ventilators, said Dr. Evans, "we did what we thought was ethical and fair. We made the best decisions we could."
Courtesy New York National Guard
During Superstorm Sandy, soldiers assigned to the New York Army National Guard evacuate patients from Bellevue Hospital on Oct. 31.
The Ontario guidelines, she said, are predicated on Sequential Organ Failure Assessment (SOFA) scores. Just as the ad hoc committee determined that of the 56 patients in the census, there were "far more folks in the red (highest priority) and yellow (immediate priority) group than we had power outlets," the group received word that the protective housing around the generator fuel pumps had failed, and total loss of power was anticipated in 2 hours.
The committee reconfigured and, among other contingencies, began assigning coverage of two providers each to the bedside of every ventilated patient, and preparing nurses to count drops per minute of continuous medication.
The ‘bucket brigade’
Although the intensivists who’d participated in Superstorm Sandy evacuations said they felt most frustrated by the lack of communication during the event, 57% said that teamwork had been essential to the success of the evacuations.
"We work as teams in our units. That is something I think we bring as a real strength to ICU evacuations," said Dr. King.
And so it was at Bellevue.
"Due to the heroics of a lot of staff and volunteers, we did not have to execute this plan," said Dr. Evans. Instead, the "Bellevue bucket brigade," using 5-gallon jugs, formed a relay team stretching from the ground floor outside where the fuel tanks were, up to the 13th, where the backup generators were located. "The fuel tank up on the 13th floor was only accessible by stepladder, so someone had to climb up there and pour the fuel through a funnel," said Dr. Evans. "But because of this, we never lost backup power, and we successfully evacuated our hospital without complications to our patients."
Individualized plan key to success
While leadership and communication were essential, said Dr. Evans, she concluded that thinking through how existing guidelines can help was also key, but did not go far enough. "Unfortunately, no document can provide for all contingencies. Complete reliance on any [guidelines] is not good. You have to think about how you would individualize things to your own facility."
The survey was sponsored by the ACCP and conducted by Dr. King as part of her role on the ACCP’s mass critical care task force evacuation panel, which will issue a consensus on the topic sometime in early 2014.
Dr. Evans, Dr. King, and Dr. Grissom reported no relevant financial disclosures.
Ten keys to ICU evacuation plan
When not under immediate threat
1) Create transport and other agreements with other facilities in region, including triage criteria.
2) Detail ICU evacuation plan, including vertical evacuation plan; simulate so all parties are familiar with their role, including those involved in patient transport.
3) Designate critical care leadership.
During imminent threat
4) Request assistance from regional facilities and appropriate agencies.
5) Ensure power and transportation resources are operable and in place.
6) Prioritize patients for evacuation.
During evacuation
7) Triage patients.
8) Include all patient information with patient.
9) Transport patients.
10) Track patients and all equipment.
Source: Dr. Colin Grissom
*This story has been updated 11/26/13