Decision Processes and Determinants of Hospital Evacuation and Shelter-in-Place During Hurricane Sandy.

CONTEXT Evacuation and shelter-in-place decision making for hospitals is complex, and existing literature contains little information about how these decisions are made in practice. OBJECTIVE To describe decision-making processes and identify determinants of acute care hospital evacuation and shelter-in-place during Hurricane Sandy. DESIGN Semistructured interviews were conducted from March 2014 to February 2015 with key informants who had authority and responsibility for evacuation and shelter-in-place decisions for hospitals during Hurricane Sandy in 2012. Interviews were recorded, transcribed, and thematically analyzed. SETTING AND PARTICIPANTS Interviewees included hospital executives and state and local public health, emergency management, and emergency medical service officials from Delaware, Maryland, New Jersey, and New York. MAIN OUTCOME MEASURE(S) Interviewees identified decision processes and determinants of acute care hospital evacuation and shelter-in-place during Hurricane Sandy. RESULTS We interviewed 42 individuals from 32 organizations. Decisions makers reported relying on their instincts rather than employing guides or tools to make evacuation and shelter-in-place decisions during Hurricane 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, which were predicted to or actually impacted continuity of operations, were the primary determinants of evacuation. CONCLUSION Evacuation and shelter-in-place decision making for hospitals can be improved by ensuring hospital emergency plans address flooding 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 evacuation versus sheltering-in-place of hospitals. In addition, administrators and public officials can improve their preparedness to make evacuation and shelter-in-place decisions by practicing the use of decision-making tools during training and exercises.