EVACUATE OR SHELTER-IN-PLACE? DECISION-MAKING FOR HOSPITALS DURING HURRICANE SANDY

When disasters are impending, public officials and hospital administrators must determine whether to evacuate or shelter-in-place hospitals. During recent hurricanes, hospitals have proven unable to sustain continuity of operations. While failure to preemptively evacuate can endanger the safety of patients and staff, evacuation is not without risk and should only be undertaken if warranted. Little is known about how evacuation and shelter-in-place decision-making for hospitals occurs in practice. This research examined evacuation and shelter-in-place decision-making for hospitals in Delaware, Maryland, New Jersey, and New York during Hurricane Sandy in 2012. State emergency preparedness laws that may have affected evacuation and shelter-in-place of hospitals were systematically identified and analyzed. Semi-structured interviews were conducted with key informants who were responsible for decision-making during Sandy. Interviews were recorded, transcribed, and thematically analyzed. At the time of Sandy, none of these states had enacted statutes or regulations explicitly granting the government the authority to order shelter-in-place of hospitals. While all four states had enacted laws explicitly enabling the government to order evacuation, the nature of this authority and the individuals empowered to execute it varied. Hospital executives reported having authority and responsibility for decision-making. In New York and Maryland, government officials stated they could order hospital evacuation whereas officials in Delaware and New Jersey said the government lacked enforcement capacity and therefore could not mandate evacuation. Key informants relied on their instincts and did not employ aids or tools to make evacuation and shelter-in-place decisions during Sandy. Risk to patient health from evacuation, prior experience, cost, and ability to maintain continuity of operations were the most influential factors in decision-making. Flooding and utility outages were the primary determinants of evacuation. States can further improve their readiness for catastrophic disasters by ensuring explicit authority to order evacuation and shelter-in-place where it does not already exist. Governmental and hospital plans should explicitly delineate decision-making processes and include explicit thresholds that, if exceeded, would trigger evacuation. Comparative risk assessments that inform decision-making would be enhanced by improved collection, analysis, and communication of data on morbidity and mortality associated with both pre- and post-evacuation versus sheltering-in-place of hospitals