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Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

ACADEMIC EMERGENCY MEDICINE 2012; 19:1088–1098 © 2012 by the Society for Academic Emergency Medicine

Abstract

On February 2, 2011, Tropical Cyclone Yasi, the largest cyclone to cross the Australian coast and a system the size of Hurricane Katrina, threatened the city of Cairns. As a result, the Cairns Base Hospital (CBH) and Cairns Private Hospital (CPH) were both evacuated, the hospitals were closed, and an alternate emergency medical center was established in a sports stadium 15 km from the Cairns central business district.

This article describes the events around the evacuation of 356 patients, staff, and relatives to Brisbane (approximately 1,700 km away by road), closure of the hospitals, and the provision of a temporary emergency medical center for 28 hours during the height of the cyclone.

Our experience highlights the need for adequate and exercised hospital evacuation plans; the need for clear command and control with identified decision-makers; early decision-making on when to evacuate; having good communication systems with redundancy; ensuring that patients are adequately identified and tracked and have their medications and notes; ensuring adequate staff, medications, and oxygen for holding patients; and planning in detail the alternate medical facility safety and its role, function, and equipment.

Resumen

El 2 de febrero de 2,011, el ciclón tropical Yasi, el mayor ciclón que ha cruzado la costa de Australia y del mismo tamaño del huracán Katrina, amenazó la ciudad de Cairns. Como resultado, tanto el hospital base como el hospital privado de Cairns fueron evacuados. Los hospitales cerraron y un centro de urgencias alternativo se estableció en un estadio deportivo a 15 km del distrito central de negocios de Cairns. Este artículo describe cómo transcurrió la evacuación de los 356 pacientes, el personal y los familiares a Brisbane (aproximadamente a 1.700 km por carretera), el cierre de los hospitales y la provisión de un centro médico temporal de urgencias durante las 28 horas del ciclón. Nuestra experiencia pone de manifiesto la necesidad de planes de evacuación hospitalarios adecuados y ensayados; la necesidad de control y órdenes claras con identificación de la persona responsable; la necesidad de una toma de decisión rápida de cuándo evacuar; de tener buenos sistemas de comunicación; de asegurar que los pacientes están adecuadamente identificados, localizados y que tienen sus medicaciones e historias clínicas; de asegurar un adecuado personal, las medicaciones y el oxígeno para asistir a los pacientes; y de planificar con detalle una alternativa médica segura y su papel, función y equipamiento.

There is increasing focus, being led by the World Health Organization (WHO), around disaster risk reduction, especially when it involves health facilities, in an attempt to reduce the loss of health care in disasters.1 The literature suggests that hospital evacuations occur globally; however, there is a paucity of published data on policy,2 and policies are often developed only after an event.3–5 A recent report highlights the dangers of evacuating hospitals, even in developed countries, with more than 50 patients dying during or just after the evacuation in Japan after the Tsunami in 2011.6 In Australia there are little, if any, published data on hospitals being evacuated, although in the Queensland floods of 2010 and 2011, five small (<50-bed) country hospitals had been evacuated and an additional four in 2011 and 2012.

On January 31, 2011, Severe Tropical Cyclone Yasi formed off Fiji. This developed into the largest cyclone to ever cross the Australian coast, with an eye more than 100 km wide and a storm size of 600 to 800 km diameter. The Australian Bureau of Meteorology predicted on February 1 that the cyclone would cross the Australian coast at Cairns, Queensland (NE Australia), at approximately 22:00 hours on February 2, coinciding with a high tide. It was also predicted that the associated storm surge could be as high as 7 m above the normal tide. Cairns Base Hospital (CBH) is located on the waterfront and was regarded as being at particular risk from storm surge. The Cairns Private Hospital (CPH) is 100 m from CBH. As a consequence of this, at 09:30 hours on February 1, the Premier of Queensland, Anna Bligh, announced a State Disaster Management Group meeting decision that CBH and CPH in Cairns would be evacuated. All patients not able to be discharged would be transported by air to Brisbane, approximately 1,700 km south. A full timeline of events is displayed in Table 1. A comparison to the United States of the distances involved, size of the cyclone, and the likely course of the cyclone when the decision was made is shown in Figures 1A through 1C.7–9 Townsville (350 km south), as the closest major facility, was not considered, both to maintain surge capacity in North Queensland and to allow the concurrent evacuation of approximately 200 patients from waterfront Townsville nursing homes, also likely to be affected by the storm surge.

Table 1.    Timeline of Events Around the Evacuation of Cairns Hospitals
DayTimeEvent
  1. ADF = Australian Defense Force; CBH = Cairns Base Hospital; CPH = Cairns Private Hospital; HEOC = Health Emergency Operations Centre; ICU = intensive care unit; SCBU = special care baby unit.

January 31, 2011 Cyclone Yasi forms off Fijian coast
February 2, 201109:30Premier Bligh announces plans to evacuate CBH and CPH
10:30ED starts planning and moving department to first floor
14:00Evacuation commenced
14:00Careflight air ambulance arrived to take one ventilated neonatal patient
15:00Royal Flying Doctor Service (RFDS) Townsville arrived to take two ventilated patients
15:00HEOC decision made to close entire CBH 07:00 February 2, 2011, and establish alternative care facility operational at 08:00 February 2, 2011
16:00RFDS Rockhampton arrived to take two critical care (one ventilated patient)
17:30Careflight Air Ambulance Lear jet arrived to take two ventilated adult patients
18:00RFDS Cairns departed with two ICU patients (one ventilated)
18:30RFDS Rockhampton arrived to take one ventilated ICU patient
19:00First patients moved from wards to ED staging post
20:30RFDS Brisbane to take four SCBU patients
21:30Arrival of RAAF aircraft two C-17s, two C-130s
22:00QANTAS chartered flight—parents, hemodialysis patients, mental health patients, medical escorts VIRGIN charter SCBU mothers
22:25RFDS Brisbane arrived to take three (two ventilated) SCBU patients
23:30Security authorized to review wards and closure once patients transferred
00:40Government jet to take nine obstetric patients
03:20RFDS Cairns departed with four neonates
03:30Careflight air ambulance arrived for five neonatal SCBU patients
05:00CBH cleared of all patients
06:30Last ADF flight departs
08:00Alternative care facility operational at Fretwell Park
08:00Last of 11 palliative patients transferred from airport to Atherton Hospital, inland ∼100 km from Cairns
09:00RFDS Brisbane departed with four neonatal patients
23:54Cyclone Yasi core crosses coast
February 3, 201112:00CBH ED reopens
image

Figure 1.  (A) Size of Australia compared to the United States.7 (B) Size of Cyclone Yasi compared to the United States.8 (C) Map of Australia and likely route of cyclone Yasi when the decision was made to evacuate Cairns’ hospitals.9 (D) The actual track of Severe Tropical Cyclone Yasi, from the Australian Bureau of Meteorology.10

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At 23:54 hours on February 2, this Category 5 cyclone with a central pressure of 930 hPa and gusts up to 285 km/hour crossed the coast at Mission Beach, approximately140 km south of Cairns (Figure 1D10). Cairns (latitude 16° South) is a city of approximately 151,00011 in NE tropical Australia, situated 1,700 km north of the state capital Brisbane. The city has two hospitals, the public hospital, CBH (∼300 beds), and the private hospital, CPH (∼150 beds). They are situated 100 m apart and are separate organizations. CBH has the only emergency department (ED), with an annual census of 50,000 presentations, which includes pediatrics and adults. CBH has all services excluding cardiothoracics, neurosurgery, and urology. CBH is 50 m from the waterfront, and CPH 100 m, both on the flood plain. CBH has two blocks dating from the 1970s. Concerns have been recently raised about the structural integrity of parts of the older block (windows and window frames) with a category 4 cyclone. The ED is in the newest block, built in the 1990s, with a wind load rating for a category 4 cyclone for all structures, although there is no window protection present.

The Australian Bureau of Meteorology uses the Australian tropical cyclone intensity scale, which describes tropical cyclones ranging from 1 (weakest) to 5 (strongest) relative to the maximum wind speed, strongest gusts, and central pressure (Table 2).12 This differs from the Saffir/Simpson Scale used in the United States, in that estimated 10-minute maximum wind gusts are used rather than 1-minute average sustained wind. A comparison of the two systems is shown in Figure 2.

Table 2.    Australian Bureau of Meteorology Tropical Cyclone Intensity Scale12
CategoryMaximum Mean Wind (km/hour)Typical Strongest Gust (km/hour)Central Pressure (hPa)Typical Effects
163–88<125>985Negligible house damage. Damage to some crops, trees, and caravans. Craft may drag moorings.
289–117125–164985–970Minor house damage. Significant damage to signs, trees, and caravans. Heavy damage to some crops. Risk of power failure. Small craft may break moorings.
3118–159165–224970–955Some roof and structural damage. Some caravans destroyed. Power failures likely. (e.g., Winifred)
4160–199225–279<930Significant roofing loss and structural damage. Many caravans destroyed and blown away. Dangerous airborne debris. Widespread power failures. (e.g., Tracy, Olivia)
5>200>279<930Extremely dangerous with widespread destruction. (e.g., Vance)
image

Figure 2.  Comparison between the Australian and the U.S. tropical cyclone severity scales.12

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Being in tropical Australia, Cairns experiences a cyclone every 2 to 3 years, and the region has experienced two Category 5 cyclones in the past 6 years. Emergency equipment is checked (generators, communications), and extra stores and resources are stockpiled at the beginning of each cyclone season (November through March). The hospital has a well-exercised process when a cyclone is likely to strike the region within 48 hours.

The hospitals’ standard practice has been to discharge home all patients who can be and then shelter in place. Staff are rostered above the usual staffing levels, with the understanding that staff may be isolated in the hospital for up to 24 hours. Others are identified to be on call and to return to the hospital when able. Although there are plans to evacuate the hospital, the plans mainly revolve around evacuating wards or a wing of the hospital. There is a plan to evacuate the entire hospital, but only to a nearby congregation point. There were no plans to evacuate patients to Brisbane, close the hospital, and establish an alternate health facility.

In Queensland, the disaster management system is a legislated response.13 The local government has the local disaster management group. This organization is responsible for the preparation for and management of a disaster. A number of local government regions are then collected together into districts based on police district boundaries. The local disaster management groups are supported within each district by a district disaster management group, which provides whole-of-government planning and coordination capacity to support local governments in disaster operations. This feeds to the state disaster management group, which is at a state government level. The state disaster group is the peak disaster management policy and decision-making body in Queensland, and it provides strategic direction and advice to the government. Membership of the state group is composed of representatives from government and nongovernment agencies at the senior officer level who have a significant role in disaster management. The federal government then supports the state disaster management group.13

The health disaster management system runs parallel to this with liaison at each level. Local health facilities feed into the local disaster management group with health service districts (and often larger referral hospitals) linking into the district group. A health incident controller (HIC) is responsible for the local health response and is supported by a Health Emergency Operations Centre (HEOC). The HIC reports to the state health coordinator who is supported by the State Health Emergency Coordination Center (SHECC), which also liaises with the state disaster management group.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

Data were sourced from postaction reports written by various departments and key individuals involved in Cairns and elsewhere in Queensland. The CBH ED staff summarized their experience and the reports and minutes from the department debrief were also accessed. CBH held a formal debrief, involving many staff at all levels of the organization, and these reports were also accessed. Authors on this paper, representing various agencies involved with the entire incident, provided summaries of their departments’ debriefs. Lessons observed were derived from all debriefs. Data were also obtained from the Queensland government’s media releases and media reports.

Using a standardized approach, all reports were reviewed and summarized by one author (ML) and reviewed by another (PA). This summary was sent to all other authors and comments were then added to the document. A search of the medical literature was also performed examining worldwide reports of evacuating hospitals, as well as policy documents from leading national and international organizations.

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

Evacuation

Cairns Response.  Following the decision to evacuate, staff were notified by line managers, with other key personnel off campus also contacted by telephone and planning for evacuation commenced. The CBH cyclone and disaster plans had already been activated prior to this announcement, and the HEOC was established with the Deputy District Executive Director of Medical Services (also an emergency physician) appointed as HIC. All patients were assessed by their respective inpatient teams to identify 1) who was able to be discharged, 2) who was able to be transferred commercially, 3) who needed to be transferred on a stretcher, and 4) who needed to be transferred on a stretcher with a high level of care. High-risk community patients, such as home dialysis and advanced pregnancy, were also identified by treating teams and included in the evacuation plans.14 Eleven patients with terminal conditions (mainly severe dementia or palliative care patients with metastatic disease) and not expected to survive for more than 72 hours were transferred by road to Atherton Hospital. Figures 3 and 4 describe the distribution of patients following the evacuation of Cairns Hospitals.

image

Figure 3.  Disposition of patients: 26 from CPH rest from CBH.

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image

Figure 4.  Flow of patients.

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Each patient had a one-page summary of his or her condition, most recent investigations, medications, and a set of observations summarized. Each patient was identified with two patient labels. All patients were fed and given simple analgesia and preflight antiemetics. During this day there were 99 presentations to the ED. Three patients who presented, or who developed potentially life-threatening complications during the evacuation, were added to the list. They required intervention and management and the decision to transfer despite the potential risks. The three patients were: 1) a female in the labor ward with a postpartum hemorrhage requiring blood transfusion, with a hemoglobin level 66 g/L; 2) a female with a stable ectopic pregnancy, diagnosed in ED; and 3) an intubated male patient with an undifferentiated head injury post assault who was retrieved from Atherton (100 km from Cairns) to Cairns International Airport for transfer to Brisbane.

In addition to the coordination of the ongoing general primary health, community, public, and mental health services response to the disaster event, the SHECC was tasked with the coordination of the emergency evacuation of the Cairns Hospitals and transport of inpatients to Brisbane hospitals, where there was collective capacity to absorb the patients. This particular coordination activity was required to be planned, resourced, and completed within a 10-hour fixed time line.

The SHECC coordination components were assembled on the announcement of the evacuation and involved:

  •  • 
    Constant real-time communication between the Cairns Hospital, the SHECC, and the State Disaster Coordination Centre.
  •  • 
    A specialist clinical assessment team to assess and allocate mode of transport categories.
  •  • 
    A specialist air desk logistic cell headed by Retrieval Services Queensland, including Queensland Ambulance Service (QAS), Australian Defence Force (ADF), and commercial airline procurement capability to manage the various air medical and air transport missions. Retrieval Services Queensland coordinates approximately 18,000 air medical transfers per year across the state and had previous experience evacuating a number of smaller hospitals, including five in the previous month, but none were larger than 50 beds.
  •  • 
    A specialist patient flow planning team to place Cairns patients in appropriate accommodation in Brisbane hospitals.
  •  • 
    A patient repatriation planning team to manage the progressive return of patients to Cairns Hospitals during the recovery phase of the disaster event (over 6 weeks).

A Code Brown (an Australian disaster category signifying an external emergency) was declared in a number of South East Queensland hospitals. The two tertiary hospitals in Brisbane (The Royal Brisbane and Women’s Hospital with 1,000 beds and The Princess Alexandra Hospital with 700 beds) were planned to accommodate approximately 100 patients each by enacting internal disaster plans. Nine hospitals, both private and public, were organized to receive (and did receive) patients from Cairns.

Evacuation Process

Patient manifests were developed electronically by CBH and CPH and sent to SHECC. This indicated the number of patients. The Royal Australian Air Force (RAAF) had paper manifests of all patients travelling on the military aircraft and this was given to the Tactical Medical Facility medical commander on arrival in Brisbane.

Patients and relatives being evacuated were brought from the wards to the ED, which was used as a staging facility. Here the patients were confirmed and then moved to the airport (∼3 km away) using bus or ambulance. Patients were moved from the hospitals to link in with the planned departure of the aircraft. This commenced at approximately 19:00 hours and proved to be a difficult undertaking. It required close liaison with QAS in regard to the urgency of transfer and timing of aircraft departure. This was especially so in the early morning when there were still a significant number of patients requiring transfer from both hospitals, and some of the aircraft (both ADF and civilian) had departed.

Thirteen aircraft were used in the transport of 356 patients, staff, and relatives to Brisbane. These involved commercial aircraft, Royal Flying Doctor Service (RFDS) aircraft, Careflight Queensland Air Ambulance, the Queensland government jet, and four RAAF aircraft (two C-17 Globemasters and two C-130 Hercules). Figure 3 describes the case mix and numbers transported by various aircraft used in the evacuation.

Departure Points

Patients departing Cairns by commercial aircraft left from the domestic terminal, patients using smaller aircraft (RFDS, government jet, Careflight jet, police air wing) used the general aviation terminal, and the RAAF used the international terminal. This meant that there needed to be staff coordinating at three different locations. Medical and nursing staff were located at the domestic and international terminals, and medical escorts were with all patients transferred to the general aviation terminal. At the international terminal, there were approximately 50 QAS paramedics available.15

Domestic Terminal.  The domestic terminal was a scene of chaos, with patients mixing with domestic passengers desperate to purchase tickets to self-evacuate from Cairns. There was some confusion with commercial airline staff, where the security and ticketing requirement for full identification, including escort names and date of birth (DOB), was an imperative. The commercial airline staff would also not issue tickets unless prepaid by Queensland Health. This was somewhat frustrating, especially for those mothers separated from their sick babies and children. After urgent liaison with SHECC, giving them the names and DOB of these passengers, tickets were issued. The last domestic flight left just after midnight.

General Aviation Terminal.  This part of the evacuation ran smoothly as this is the normal process and terminal used, for patients transferring by RFDS or similar air ambulances. A total of 26 critical care Intensive Care Unit and Special Care Baby Unit patients were moved via Queensland’s air medical emergency medical system assets, as well as the government jet.

International Terminal.  There were no international flights due that evening, so the International Airport check-in lounge, with the permission of the Cairns Airport Authority, was used to stage patients waiting for arrival of aircraft. It provided shelter and limited toilets and seating. Further equipment, drinking water, medications, and dressings were sent from the hospital as required. There was a limited oxygen supply, mainly cylinders supplied by the QAS. Problems included the lack of food for patients; the temperature inside the lounge, as the air conditioning was initially turned off with no flights expected; limitations on the number of power points to charge monitoring equipment; and limited patient trolleys. QAS ambulances cycled between the hospitals and airport, bringing extra staff with the patients and a number of trolleys from the ED.15

Once the RAAF arrived, the patients were reviewed by the RAAF Senior Medical Officer and the CBH Medical Commander, who fortunately had a preexisting working relationship, being involved in Australian Medical Assistance Team training courses and the Pakistan floods deployment in 2010.16 Once patient identification, destination, and condition were confirmed, the patient was moved to one of four aircraft. During this entire process there was excellent cooperation between the ADF, QAS, State Emergency Services, Airport Fire Service, employees of the Cairns Airport, and medical and nursing staff from both the CBH and the CPH.

The RAAF aircraft were staffed with military medical personnel (mainly RAAF evacuation teams) and staff from the RFDS Brisbane and a Brisbane ED. The aircraft were configured for medical evacuation, although they did not have as much oxygen as was required for transfer. There was limited food, but all patients had been fed prior to leaving the hospital.

We were fortunate that the mobile phone network and Internet remained operational throughout the evacuation and use of radios was not needed. The lead in each of the areas (CBH, the ED, and the international airport) had a liaison person assigned. The Internet remained operational and allowed for direct written communication to SHECC in Brisbane.

The last RAAF flight left at 06:30 hours and the last RFDS flight out of Cairns was 09:00 hours. This was the last aircraft to leave Cairns before the airport was closed. The cyclone crossed the coast at 23:54 hours on February 2, 2011.

Reception of Patients in Brisbane

In close liaison with QAS, a tactical medical facility was established at Brisbane Airport to provide a staging post for stretcher patients while awaiting loading into QAS road ambulances. All patients arriving by the RAAF or commercial flights were retriaged by medical teams and liaised with SHECC who had preidentified to which hospital each patient would be transferred. Coordinated movement of patients by QAS road ambulance and buses was facilitated by the State Disaster Coordination Centre and local emergency services, transporting patients to their allocated destination hospitals in the southeast corner. Patients were transferred to nine hospitals, both private and public. All patients survived the flight and were not subject to any reported complications.

Ongoing Provision of Care to the Cairns Community

1. The ED.  Planning for movement of patients and assessment of staff commenced following the announcement of Code Brown at 10:00 hours. This complex situation involved an initial assessment of the department activity, initial plan for relocation of ED to the first floor, the movement of current patients, and staff availability for the next 36 hrs.

Contact was made with all staff, either directly or by phone. Most staff found the decision difficult, balancing the needs of their own families with that of the community. This was especially so with the media and public advice from the State Disaster Management Group to leave Cairns.

During the afternoon of February 1, the ED was relocated to the recovery area on the first floor (on level above the ground floor). At 15:00 hours the decision was made by the CBH HEOC to close the hospital to all patients and to set up an alternative off-site emergency medical center to provide basic emergency care to the community. This decision was based on the risk of storm surge with associated power failure and inability of the community to access the facility due to flooding and road closures. The ground floor and temporary first floor ED were both closed on February 2 at 07:00, and all emergency care to the city of Cairns was provided by the emergency medical center at Edmonton, approximately 10 km south of the hospital. CBH ED reopened at midday on February 4. No patients were transferred from CBH ED to the emergency medical center when the CBH ED closed.

2. Emergency Medical Center.  A sporting complex in Edmonton was previously identified by the Heath Service District as a potential additional facility to be used for health purposes in the event of a natural disaster. This was based on the size of the facility, its close proximity to key communication and prehospital resources, distance from identified storm surge areas, and location within the main population density of the city. However, it was never anticipated, neither were any plans made, to utilize the facility as an alternative hospital.

The anticipated function of the emergency center was ill-defined, and preparations and logistical planning were necessarily rushed and ad hoc. Equipment and medical supplies were transported by trucks from CBH, with many essential items delayed until late on February 2. Staffing relied on the goodwill of mainly junior medical and nursing staff. Clinical staff were supported by engineering and maintenance staff in the initial setup of clinical areas within the sports complex.

After the emergency center setup was complete, there were concerns raised by Queensland Fire and Rescue Service about the safety of the building in the event of category 5 wind gusts. Modifications such as covering all windows with boards, provision of three-phase power backup, and the supply of a commercial generator were made.

The emergency center was operational for 28 hours, and for this period of time was the only facility providing health care to the Cairns community. Seventy-six patients were treated during this time, with problems including snakebite, acute coronary syndrome, asthma, croup, and fractures. Of particular note, there were three normal deliveries and one complex and prolonged breech labor. A child was treated for a severe respiratory illness complicated by respiratory arrest. There were no documented adverse patient outcomes.

Transition to Normal Practice and Return of Patients to Cairns

Cairns Base Hospital ED reopened at midday on February 3, with the closure of the emergency center in Edmonton. It took several hours for the ED to return to full function due to delays in transporting essential equipment, as well as staffing limitations, given that many had moved south and were unable to return to Cairns rapidly. Five patients were moved back to CBH. The first 24 hours back in the ED were exceptionally busy, with 181 patients seen on February 4 (21% above the daily average of 150 patients). As such, the hospital rapidly filled with patients, which had implications for patient repatriation from Brisbane and affected Brisbane hospital function. An RAAF C-130 Hercules returned 35 patients 1 week after the cyclone, and there were daily air ambulance transfers of two to four patients from Brisbane for approximately 3 weeks. There were also difficulties in tracking patients and their outcomes in the south east Queensland hospitals.

Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

This was the largest evacuation of a hospital in Australia, moving 356 patients, staff, and relatives over 1,700 km by air medical transfer to the state capital, Brisbane. There was no loss of life, nor any adverse health events for those transferred. This was all done under the threat of the largest cyclone to hit the Australian coast. The hospital was closed, and an alternative medical facility was established in a sporting complex that provided health care to the community for 28 hours and treated 76 patients in this time.

The evacuation of a hospital is a rare event. There are limited published data around hospital evacuation.1 In one paper, 275 hospital evacuations were reported in the United States from 1971 to 1999, with only six before 1980.17 A recent report from Japan highlighted the risks of evacuating hospitals. It detailed the deaths of more than 50 patients who were evacuated after the tsunami in March 2011. Patients were not escorted the 100 km they were transferred and died due to dehydration, hypothermia, and worsening of their medical conditions.6 The report discussed how there were no prior plans to evacuate the hospital.

The experiences and lessons observed by other facilities involved in evacuating their hospitals are similar to ours.2,3,18,19 These include having identified key personnel to command and coordinate the evacuation, the establishment of a command center, deciding to evacuate early, the need for good communication, good documentation of patients being transferred, and the use of battery-powered medical equipment and the issues associated.2,18,19 The evacuation of a hospital has such significant implications, especially in the developing world, that the WHO in combination with the Pan American Health Organization, The World Bank, and the International Strategy for Disaster Reduction has since 2008/2009 developed the global campaign “Hospitals safe from disasters: reduce risk, protect health facilities and save lives.”1 The program emphasizes the need for making hospitals safe from disaster (risk reduction). Planning documents from the United Kingdom20 and the U.S. Government Accountability Office reports4,5 both highlighted the need for better organization and process around evacuations of hospitals. Both reports were as a result of hospital evacuations, being evacuation of five London Hospitals due to fires (in 2008/2009)3 and Hurricane Katrina (United States).4,5

In the five London hospital fires, two hospitals (The Royal Marsden, a 240-bed cancer center; and The Chase Farm Hospital, a medium secure psychiatric unit) were completely evacuated, while another three (University College Hospital, Great Osmond St. Hospital, and Northwick Park Hospital) were partial evacuations. In the summary report, the National Health Service identified seven “key lessons learned” areas.3 These are summarized in Table 3. Many of these issues were similar to our experience and were also similar to those reported by others in the American evacuating hospitals.18,19

Table 3.    Summary of Lessons From the Evacuation of Five London hospitals Due to Fire14
Key Lessons from London Hospital FiresIssues Raised
1. PlanningDeveloped evacuation plans
Available site maps
Adequate insurance cover
2. Command and controlClear command and control
Tabards identifying key staff
Designate who are the decision makers
Availability of alternative control rooms
Recovery team planning
3. CommunicationAlternate communication devices, communication with external agencies early
Patient notes with patients
Mechanism to track patients
Triage of patients at leaving facility so patient goes to correct location
Ensure adequate ambulance support
Off site shelter for initial patient holding
Detailed planning for critical care, mental health, immunosuppressed, and other special patient groups
Patient medication supply
4. StaffEnsure staff safety and all staff safe
Support staff
5. MediaManage the media
Have a media strategy
Dedicated spokesperson
6. Post eventPredetermined recovery plan
Debriefing plan
Event report essential
7. Training and exerciseRegular staff training
Regular evacuation drills

We were extremely fortunate to have access to a number of RAAF aircraft and personnel to assist in the evacuation. The ADF are normally extremely busy21 and have limited aviation assets that were fortunately in Australia at the time of this evacuation. If these assets were not available, it would have made this evacuation more challenging and is an area that needs further planning.

Lessons Observed

Although a successful evacuation, there were many lessons that we observed.

1. Patient issues

a. Patient manifest. We struggled to have a timely available manifest of all patients being transferred from both the public and the private hospitals. We believe that a standardized list needs to available. This would include patient demographics including name, DOB, allergies, weight, and oxygen requirements.

b. Tracking system. We did not have a good system to track patients through their whole journey from leaving our hospital to arriving at the destination hospital in SE Queensland. We used a paper system at each location, but a centralized electronic system would have been better.

2. Equipment

a. Medications. Patients sent to the airport for evacuation did not have their regular medications. Many had complex medical issues. We believe that all patients should have had on them at least 24 hours of their usual medication.

b. Oxygen. There were many patients transferred who required oxygen with limited oxygen available for the transfer and at the airport. We needed to better identify and coordinate oxygen requirements, especially when dealing with the ADF or other outside agencies.

c. Transport monitoring. There were a number of unwell patients (critical care unit/high dependency unit) who required monitoring, both at the airport and during transport. There was limited monitoring available, and we needed to better identify this requirement.

d. Battery power. Most portable medical equipment is battery-powered, and in the airport there were limited power sources. This needs to be planned for.

e. Communication. We were very fortunate that the mobile phone network and Internet were working. Due to the nature of the evacuation, communication was essential and planning should ensure that backup systems are available.

3. Staffing

a. Coordination of response. The early establishment of the hospital HEOC and SHECC, as well as the appointment of key experienced personnel to coordinate the evacuation, was essential in the successful evacuation of the Cairns hospitals.

b. Disaster staffing requirements. This is a difficult issue. During the evacuation, the state disaster management authorities were advising Cairns residents to leave the city. This presents significant challenges for all staff, in preparing their own homes and families for the impending cyclone, as well as preparing the patients for transfer and the temporary medical facility

c. Colocation. At the airport it was difficult with the three locations coordinating the transfer of patients. It would have been easier to have a central point to receive all patients and subsequently transfer from.

d. Experience. We found that having staff who were experienced in disaster response and air medical retrieval was extremely beneficial. This was both in Cairns and in the coordination centers in Brisbane. The value of established relationships was also significant, as many of these staff had worked together previously and were able to rapidly develop a working system.

e. Liaison between health facilities/outpatient care centers. There was excellent cooperation between all health facilities both in the Cairns region and in SE Queensland. There was some difficulty getting an accurate picture of the number of patients to be transferred from the private hospital, and the need to have closer disasters arrangements between private and public hospitals is an area that is being addressed.

f. Provision of suitably located, staffed, and equipped casualty clearing post. With the large number of patients in the airport, we should have set up a formal casualty clearing post to care for the patients awaiting transfer. Ideally this should be staffed by personnel from elsewhere to preserve Cairns capacity. It is suggested that in future events an aircraft should be sent early with a forward team to assist with liaison and establishment of the casualty clearing post, with a full team sent on the first evacuation flight to staff the clearing post.

g. Matching of neonates and mothers in Brisbane. We needed to have a better system so we could match the mothers and neonates once in Brisbane.

4. Emergency medical facility

a. Need for a structured plan for the establishment of an alternate facility. We did not have a plan to establish such a facility. This plan (which is now being finalized) needs to include a number of buildings (e.g., university, schools) that we could use and a process on how we would activate it, staff the facility, and equip it. Of note, the state government is also fast-tracking a plan to build an alternate health facility to be used as a day surgery/primary health care facility (away from the hospital) that could be used as an alternate medical facility if this event occurred again.

Limitations

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

This study’s data are qualitative. We have not been able to test our observations to see that if we improved on our “lessons” we would improve the way we evacuated our hospital. We do note that many of our lessons have been previously reported by other organizations involved in hospital evacuations.2,3,5,17,19,20

Conclusions

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

This was the largest evacuation of a hospital in Australia. We were able to successfully transfer 356 patients, staff, and relatives approximately 1,700 km, to Brisbane, within 22 hours of being notified of the need to evacuate. All patients survived their flights and were not subject to any reported complications.

Following this experience we have been able to identify many things that worked well, but also a number of areas where further improvement is needed. All health facilities need to have plans for evacuation of their facility and establishment of alternative care facilities. Health facilities that are geographically isolated need to consider long-distance evacuation in their planning arrangements, while jurisdictions should have prestanding arrangements to manage the evacuation of these facilities and reception of patients elsewhere. As we have done, hospitals also need to identify facilities that may be used as a temporary medical facility, if the major facility is closed.

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References