PIIS0012369215519892

[ Evidence-Based Medicine ]
Evacuation of the ICU

Care of the Critically Ill and Injured During Pandemics and Disasters:
CHEST Consensus Statement
Mary A. King, MD, MPH, FCCP; Alexander S. Niven, MD, FCCP; William Beninati, MD; Ray Fang, MD; Sharon Einav, MD;
Lewis Rubinson, MD, PhD; Niranjan Kissoon, MBBS, FRCPC; Asha V. Devereaux, MD, MPH, FCCP;
Michael D. Christian, MD, FRCPC, FCCP; and Colin K. Grissom, MD, FCCP; on behalf of the Task Force for Mass Critical Care
BACKGROUND: Despite the high risk for patient harm during unanticipated ICU evacuations,
critical care providers receive little to no training on how to perform safe and effective ICU evac-
uations. We reviewed the pertinent published literature and offer suggestions for the critical care
provider regarding ICU evacuation. The suggestions in this article are important for all who are
involved in pandemics or disasters with multiple critically ill or injured patients, including
front-line clinicians, hospital administrators, and public health or government officials.
METHODS: The Evacuation and Mobilization topic panel used the American College of Chest
Physicians (CHEST) Guidelines Oversight Committee’s methodology to develop seven key
questions for which specific literature searches were conducted to identify studies upon which
evidence-based recommendations could be made. No studies of sufficient quality were identified.
Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process.
RESULTS: Based on current best evidence, we provide 13 suggestions outlining a systematic
approach to prepare for and execute an effective ICU evacuation during a disaster. Interhospi-
tal and intrahospital collaboration and functional ICU communication are critical for success.
Pre-event planning and preparation are required for a no-notice evacuation. A Critical Care
Team Leader must be designated within the Hospital Incident Command System. A three-
stage ICU Evacuation Timeline, including (1) no immediate threat, (2) evacuation threat,
and (3) evacuation implementation, should be used. Detailed suggestions on ICU evacuation,
including regional planning, evacuation drills, patient transport preparation and equipment,
patient prioritization and distribution for evacuation, patient information and tracking, and
federal and international evacuation assistance systems, are also provided.
CONCLUSIONS: Successful ICU evacuation during a disaster requires active preparation, par-
ticipation, communication, and leadership by critical care providers. Critical care providers
have a professional obligation to become better educated, prepared, and engaged with the
processes of ICU evacuation to provide a safe continuum of critical care during a disaster.
CHEST 2014; 146(4_Suppl):e44S-e60S
ABBREVIATIONS: CCTL 5 Critical Care Team Leader ; ECMO 5 extracorporeal membrane oxygenation;
EOC 5 emergency operations center; NDMS 5 National Disaster Medical System
Revision accepted May 1, 2014; originally published Online First Medicine, Salt Lake City, UT; University of Maryland Medical Center
August 21, 2014. (Dr Fang), Baltimore, MD; Shaare Zedek Medical Center (Dr Einav),
AFFILIATIONS: From University of Washington (Dr King), Harborview Hebrew University Faculty of Medicine, Jerusalem, Israel; R. Adams
Medical Center, Seattle, WA; Madigan Army Medical Center (Dr Niven), Cowley Shock Trauma Center (Dr Rubinson), University of Maryland
Uniformed Services University of Health Sciences, Tacoma, WA; Inter- School of Medicine, Baltimore, MD; BC Children’s Hospital and Sunny
mountain Tele-Critical Care (Dr Beninati), University of Utah School of Hill Health Centre (Dr Kissoon), University of British Columbia,
e44S Evidence-Based Medicine [ 146#4 CHEST OCTOBER 2014 SUPPLEMENT ]

Summary of Suggestions 3b. We suggest preidentifying unique transport
resources that are required for movement of specific
Form Hospital and Transport Agreements
populations, such as critically ill neonates, children,
1a. We suggest local and regional mutual-aid and technology-dependent patients, at a regional
agreements should be established with other appro- level. This information can then be used in real time
priately staffed and resourced hospitals to redistribute to match allocated resources to patients.
critically ill and injured patients from an evacuating
3c. We suggest conducting detailed and realistic
hospital(s), and these agreements should be inte-
exercises that require ICU evacuation with local and
grated within the framework of disaster preparedness
regional ground and air transport agencies.
plans.
1b. We suggest creation of predisaster formal Designate a Critical Care Team Leader
agreements between hospitals and transport agencies
4a. We suggest the Incident Management System at
or between Health Coalitions or Regional Health
the evacuating ICU hospital should support early and
Authorities and transport agencies for air or ground
frequent communication between Incident Command
transport of critically ill patients during a disaster.
and a designated Critical Care Team Leader (CCTL)
during an impending evacuation to provide close
Prepare for and Simulate Critical Care Evacuation coordination and support of ICU evacuation
2a. We suggest staffing requirements within disaster preparations.
plans should take into account the staffing resources 4b. We suggest the CCTL coordinating the critical
necessary for desired surge capability to both safely care evacuation should be responsible for (1)
move patients and to provide continuous care for categorizing ICU patients by ICU resource require-
patients remaining in the ICU. ment and (2) communicating these ICU patient
2b. We suggest developing a detailed vertical evacua- resource requirements with the Hospital Incident
tion plan using stairs when applicable for critically ill Command and to any Regional or National Emer-
and injured patients. gency Command Center supporting hospital
evacuation.
2c. We suggest hospital exercises should simulate a
mass critical care event and include vertical evacua- 4c. We suggest when preparing for and during an ICU
tion when applicable that evaluates (1) patient evacuation, a primary role of the CCTL should be to
movement using specialized evacuation equipment categorize each candidate ICU patient evacuee by
and (2) the ability to maintain effective respiratory (1) ICU resources required and (2) skill set of trans-
and hemodynamic support while moving down stairs. port staff required.
4d. We suggest CCTLs and staff should receive special
Prepare for and Simulate Critical Care Transport training, education, and practice on patient categori-
3a. We suggest specialized care is resource intensive, zation and transport requirements.
and specialized ground and aeromedical teams may 4e. Expert providers from evacuation teams and
be required to ensure appropriate initial and ongoing outside facilities, when possible through face-to-
care prior to and during evacuation. face communication on site, can help ensure
Vancouver, BC, Canada; Sharp Hospital (Dr Devereaux), Coronado, CA; DISCLAIMER: American College of Chest Physicians guidelines and
Royal Canadian Medical Service (Dr Christian), Canadian Armed Forces consensus statements are intended for general information only, are not
and Mount Sinai Hospital, Toronto, ON, Canada; and Intermountain medical advice, and do not replace professional care and physician
Medical Center (Dr Grissom), University of Utah, Salt Lake City, UT. advice, which always should be sought for any medical condition. The
FUNDING/SUPPORT: This publication was supported by the Coopera- complete disclaimer for this consensus statement can be accessed at
tive Agreement Number 1U90TP00591-01 from the Centers of Disease http://dx.doi.org/10.1378/chest.1464S1.
Control and Prevention, and through a research sub award agreement CORRESPONDENCE TO: Mary A. King, MD, MPH, Pediatric Trauma
through the Department of Health and Human Services [Grant 1 - Intensive Care Unit, Harborview Medical Center, 325 9th Ave, Box
HFPEP070013-01-00] from the Office of Preparedness of Emergency 359774, Seattle, WA 98104; e-mail: maryking@uw.edu
Operations. In addition, this publication was supported by a grant from © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of
the University of California–Davis. this article is prohibited without written permission from the American
COI grids reflecting the conflicts of interest that were current as of the College of Chest Physicians. See online for more details.
date of the conference and voting are posted in the online supplementary DOI: 10.1378/chest.14-0735
materials.
journal.publications.chestnet.org e45S
appropriate transport planning and distribution obstruction. This requires capability to deliver a high
based on available resources during transport and minute ventilation, high flow, and high positive
in receiv ing facilities. end-expiratory pressure. They should be safe (discon-
nect alarm) and relatively easy for staff to operate.
Initiate Pre-Event ICU Evacuation Plan 7b. We suggest availability of adequate portable
5a. If pre-event hospital evacuation of critically ill energy and medical gas flexible ventilators that can
patients might be required, then we suggest planning provide accurate small tidal volumes or pressure
for patient evacuation or shelter in place using an limits for the premature and neonatal patients
Incident Command System should begin as early as expected at designated hospitals (for instance pediat-
possible. Possible strategies include shelter in place, ric centers or hospitals with a neonatal ICU). Special
partial evacuation, or early evacuation, depending on consideration should be given to creating a standard,
the circumstances. quickly accessible regional stockpile of mechanical
ventilators for evacuation of neonatal patients as it
5b. We suggest Hospital Incident Command during a may not be feasible for some nonpediatric centers to
threatened hospital evacuation should have a clear have adequate numbers of portable energy and gas
and direct mechanism for communication with local flexible neonatal ventilators.
governing bodies that control the timing and issuance
of regional evacuation orders. To prevent obstruction
Prioritizing Critical Care Patients for Evacuation
of ground medical transport during hospital evacua-
tion, coordination with local government regarding 8. We suggest evacuation order and identification of
timing of recommendations for evacuation of the appropriate facility should be based on the following
general population may be required. Efficient ground factors:
medical transport of patients during a hospital 8a. In a time-limited evacuation, less critical patients
evacuation may be facilitated by providing a time can be evacuated faster and with fewer resources per
period for hospital evacuation prior to recommenda- patient and, thus, may be moved first in order to
tions for evacuation of the general population. evacuate the most patients in the fastest time.
8b. When there is adequate time for evacuation, then
Requesting Assistance for Evacuation more critically ill patients may be moved first and in
6a. We suggest during a disaster or pandemic that parallel with less ill patients. Similar acuity patients
overwhelms local and regional resources and requires often use similar transport resources and strain the
large-scale hospital evacuations assistance, from same group of sending staff members. Thus, moving
national and/or international government medical both the less critical and more critical patients
support and evacuation agencies should be requested. simultaneously in parallel, as compared with sequen-
tially in series (when there is adequate time to
6b. We suggest the CCTL should be aware of the
evacuate the entire hospital), may decrease the overall
process for requesting evacuation assistance and the
time to evacuation.
resources available at a regional and national level.
8c. In some situations, moving groups of similar-type
Ensure Adequate Power and Transport Ventilation
patients to a single hospital entity may enable the
Equipment
sending hospital to provide staff to a single location
to facilitate continuity of care and allow receiving
7a. We suggest surge ventilators with flexible electrical hospitals to preplan to surge for specific types of
power and oxygen requirements should be available patients and cluster disaster resources.
to support patients with respiratory failure that can
maintain function while either (1) sheltering in place 8d. The most critically ill patients dependent on
or (2) evacuating to an outside facility. These ventila- mechanical devices for life support may, in some
tors should be portable, run on alternating current conditions, be safely cared for with a shelter-in-place
power with battery backup, and have the ability to run strategy if it is deemed the risk of evacuation is too high.
on low-flow oxygen without a high-pressure gas
source. Surge ventilators may be of limited capability Critical Care Patient Distribution
but should be able to ventilate and oxygenate patients 9a. We suggest during isolated, small, or pre-event
with acute lung injury or ARDS as well as airflow ICU evacuations, CCTLs should coordinate with

Hospital Incident Command and identify receiving institution for ongoing care of the remaining
hospitals for patient evacuation via the usual practice patients.
of provider-to-provider communication. 10c. We suggest evacuation planning and coordi-
9b. We suggest during multiple-facility, large, or nation should include the provision of additional
late ICU evacuations, the usual provider-to- expert providers, staff, and equipment to assist
provider system of communication for identification in the ongoing provision of care in situations where
of receiving facilities should be augmented by patient volume, acuity, or nature of illness or
other Regional or National Incident Management injury exceeds the capabilities of the CCTL and
Systems. staff.
9b.i. Every hospital should be specifically affiliated 10d. We suggest utilizing a staging area for patients
with (and drill evacuation with) a Regional or prepared and awaiting transport. This area should
National Command Center for such events. Regional ideally be located near the point of embarkation
or National Command Centers may need to assume and be staffed by medical personnel with training and
responsibility for designation of the receiving facil- experience in critical care evacuation. These personnel
ities for their patients. should be prepared to provide triage and perform
9b.ii. We suggest when a Regional or National ongoing medical care interventions prior to transport.
Emergency Command Center assumes responsibility The area should have the capability for additional
for patient distribution, they should be responsible surgical and medical stabilization pretransport if
for identifying receiving facilities that match ICU necessary.
patient resource requirements.
Sending Critical Care Patient Information With
9b.iii. We suggest the Regional or National Emergency
Patient
Command Center should enlist assistance of regional
specialist experts to assist in the above matching 11a. We suggest electronic transfer of patient infor-
process for distribution of patients requiring highly mation to the receiving hospital is optimal because a
specialized care among receiving centers. complete medical record can be included. Electronic
transfer may be through an intranet or by copying
9c. We suggest assignment of transportation resources
patient information onto a USB flash memory drive
and lines of critical care patient evacuation should
or compact disk and transferring the information
follow common existing referral patterns provided
with the patient (see the “Business and Continuity of
receiving facilities retain adequate capacity to care for
Operations” article in this consensus statement).
these patients.
11b. We suggest a paper medical record be required to
9d. We suggest patients who require advanced
travel with the patient because there may be no ability
specialty care should be directed to high-volume
to send an electronic copy of the medical record, or
centers and distribution take into account the capacity
the receiving facility may not be able to read the
and resources required to provide ongoing care to
electronic format of the medical record. A backup
these patients.
paper system may require (a) a printed copy of the
electronic medical record or (b) a handwritten patient
Preparing the Critical Care Patient for identification on a standardized patient tracking
Evacuation form. Any paper system should include basic patient
10a. We suggest standardized preparation of critically identification, problem lists, and medications on
ill patients should be performed prior to hospital-to- forms that travel with the patient.
hospital transfer, including initial stabilization,
diagnostic procedures, damage control procedures, Transporting Critical Care Patients to Receiving
and medical interventions, to address anticipated Hospitals
physiologic changes during transport. 12a. We suggest transportation methods should
10b. We suggest the transport team should provide prioritize moving the greatest number of patients as
the equipment used for transport to ensure rapidly and safely as possible to locations with ade-
compatibility and familiarity during transport quate capacity and expertise where definitive care can
and retain important resources at the source be provided.
12b. We suggest local evacuation of highest acuity evacuation of multiple patients is required and power,
patients to hospitals with additional capacity by communication, and transportation are compromised.
ground or rotary transport may be most appropriate Timely, effective, and safe evacuation of critical care
to minimize risk and reduce ongoing critical care patients is essential in a disaster, but many critical care
demands at the incident facility. providers receive little to no training in evacuation
12c. We suggest alteration in the usual standards for preparedness and implementation. Disaster planners
modes of transport may be required during a disaster and leaders also often have little critical care expertise
where transport resources are overwhelmed and and yet, are frequently responsible for ICU evacuation
evacuation and transport of critically ill patients to a when an actual event occurs.
receiving hospital ICU is required. Typical emergency medical service providers lack
the skill set required to transfer complex, critically
ill patients once intensive care interventions are
Tracking Critical Care Patients and Equipment
initiated; thus, they are unfamiliar with or under-
13a. We suggest tracking of patients should com- equipped for the numerous care requirements and
mence in the sending clinical unit, continue to the considerations in these patients. Critical care transport
point of embarkation, and if possible, continue to the providers are familiar with the critical care patient
destination facility. Tracking of the patient and and interventions, but these providers are in limited
equipment should commence prior to being loaded supply. Evacuation of quaternary academic centers is
onto the transportation. Minimum data sets for especially fraught with problems because they are
tracking should include the patient first and last typically receiving facilities; they have little practice
name, date of birth, medical record number or tracking or systems in place to serve as sending facilities.
number or triage number, time leaving facility, Documentation systems for simultaneously moving
transportation company name and transport vehicle multiple, very complex patients from an ICU setting
number, and expected destination and next are not established, and direct physician-to-physician
of kin. and nurse-to-nurse communication may no longer be
13b. We suggest both the evacuating and receiving possible during transfer of care. The ability to generate
hospitals should track patients and equipment. detailed transfer summaries and to copy records and
13c. We suggest tracking systems may be electronic images may be limited by infrastructure damage and
or paper. In the event of complete power failure, inadequate time.
however, a redundant paper system for tracking of This ICU evacuation scenario, evident during
patients and equipment should be performed by both Hurricanes Katrina, Gustav, Ike, and Sandy, high-
sending and receiving hospitals, with communica- lights the need for critical care providers to learn,
tions provided to the sending hospital and/or a plan, and train in all aspects of an ICU evacuation to
centralized coordinating center to confirm receipt of ensure safe patient transfer. ICU evacuation was not
the patients. included as a central topic in the prior American
13d. We suggest evacuation drills should test tracking College of Chest Physicians (CHEST) consensus
of patients and equipment both by electronic and statement; this consensus development process and
paper systems. literature search, therefore, was created de novo. The
topic panel elected to review the literature and
Introduction present the data from the perspective of the ICU
Recent disasters have revealed that critical care units, medical director faced with an ICU Evacuation
whether small community hospital ICUs or quaternary Timeline (Fig 1).
academic specialized ICUs, may be required to The suggestions in this article are important for all
evacuate their patients with limited pre-event notice. involved in a disaster or pandemic with critically ill
Critical care patients are especially vulnerable during patients, including front-line clinicians, hospital
evacuation because they are medically fragile and administrators, and public health or government
require special equipment and expertise. The typical officials. Although it is important for all providers to be
day-to-day transfer system of critically ill patients with familiar with critical care evacuation, Table 1 provides
direct provider-to-provider discussion and transfer an overview of the suggestions of most interest to each
paperwork can easily fail during a disaster when rapid group.

Figure 1 – ICU Evacuation Timeline.
We recommend this timeline as a
general approach for ICU evacuation
preparation and performance. The
suggestions included in this article
correspond by number to these steps.
Similar to the three tiers for Crisis
Standards of Care (conventional,
contingency, and crisis), ICU
evacuation comprises three stages:
(1) no immediate threat, (2) ICU
evacuation threat, and (3) ICU evacu-
ation. Note that the ICU Evacuation
Timeline is a continuum, with overlap
between stages because many of the
later-stage steps are actually initiated
at an earlier stage (eg, preparation of
patient information).
Materials and Methods emphasis on hospital-based care and considerations, specific disaster
episodes, and critical care transportation experience or systems.
The Evacuation and Mobilization topic panel followed the CHEST
Guidelines Oversight Committee’s methodology to develop sugges- Exclusion criteria included disaster articles without information on
tions (see the “Methodology” article by Ornelas et al1 in this consensus patient transport and evacuation or with an emphasis on prehospital
statement). The Evacuation and Mobilization topic panel developed care or care of chronic, stable populations requiring technology and
seven key questions, and four literature searches were conducted to ongoing medical care during disasters. A total of 139 of 519 articles
identify evidence on which to base suggestions, using the PubMed/ were selected for critical review. Despite this exhaustive search of the
MEDLINE database (see e-Appendix 1 for a list of key questions and literature, no studies of sufficient quality were identified upon which
corresponding search terms and results). Searches were limited from to make evidence-based recommendations. Therefore, the panel devel-
1980 to 2012. Inclusion criteria included English-language articles with oped expert opinion-based suggestions using a modified Delphi
a focus on patient evacuation (either in general or during a disaster), process.
Results or regional coordination.3 Important considerations in

planning agreements are (1) identification of regional
Form Hospital and Transport Agreements
critical care capacity and specialty resources4; (2) prior
1a. We suggest local and regional mutual-aid designation and centralized, coordinated deployment of
agreements should be established with other appro- ground and air transport with critical care capabilities5,6;
priately staffed and resourced hospitals to redistribute (3) stereotyped evacuation patterns based on volume
critically ill and injured patients from an evacuating and severity; and (4) special needs of critically ill
hospital(s), and these agreements should be inte- patients.7-9 One advantage of creating these mutual-aid
grated within the framework of disaster preparedness agreements is the identification of patient populations
plans. that would be best served at specific preidentified
1b. We suggest creation of predisaster formal facilities, similar to the New York City schema achieved
agreements between hospitals and transport agencies with preidentifying burn disaster receiving hospitals.10
or between Health Coalitions or Regional Health Mutual-aid agreements often are complex to develop
Authorities and transport agencies for air or ground and negotiate; therefore, it is important that these are
transport of critically ill patients during a disaster. secured well in advance of a disaster or pandemic rather
Critical care providers should participate in a hospital than attempting to arrange them just before or during
or region-wide process to identify risks and vulnerabil- an event.
ities and create a written plan for evacuation within and A large number of disaster case reports indicate a lack
from their hospital.2 Although most guidelines focus on of preidentified recipient hospitals, specifically during
a centralized command system to govern evacuation 9/11,11 Hurricane Katrina,12,13 the Fukushima Nuclear
decisions and movement, flexibility and redundancy Plant crisis,14 and Hurricane Sandy.15 Few hospitals and
should be retained in decision-making. Small-scale regional health-care coalitions have created mutual-aid
events may allow sufficient planning time to use normal agreements for this purpose.16,17 Even fewer hospitals or
transfer patterns and practices; major large-scale events coalitions, however, have used such agreements; when
or significant infrastructure damage may require off-site they have, financial compensation for patient transfer
TABLE 1 ] Primary Target Audiences for Suggestions and proper credentialing of outside providers have been
cited as significant challenges.18 Hospitals and coalitions
Public
Hospital Health and should consider defining the process of provider
Suggestion Clinicians Administrators Government credentialing, repatriation, and payment for services
1a 9 9 9 rendered once a crisis resolves.18
1b 9 9 9
2a 9 9 Prepare for and Simulate Critical Care Evacuation
2b 9 9
2a. We suggest staffing requirements within disaster
2c 9 9
plans should take into account the staffing resources
3a 9 9
necessary for desired surge capability to both safely
3b 9 9
move patients and to provide continuous care for
3c 9 9
patients remaining in the ICU.
4a 9 9
2b. We suggest developing a detailed vertical evacua-
4b 9 9
tion plan using stairs when applicable for critically ill
4c 9 9
and injured patients.
4d 9 9
4e 9 9
2c. We suggest hospital exercises should simulate a
mass critical care event and include vertical evacua-
5a 9 9 9
tion when applicable that evaluates (1) patient
5b 9 9 9
movement using specialized evacuation equipment
6a 9 9 9
and (2) the ability to maintain effective respiratory
6b 9 9 9
and hemodynamic support while moving down
7a 9 9
stairs.
7b 9 9
In US hospitals, disasters are due to (in order of
8a 9 9 9
decreasing frequency) fire, hazardous material events,
8b 9 9 9
hurricane damage, human threats, earthquakes,
8c 9 9 9
flooding, and utility failure.19 More than 50% of
8d 9 9 9
hospital evacuations are due to internal hospital events,
9a 9 9 9 but the most severe problems and largest scale
9b 9 9 9 hospital evacuations have been due to natural hazards.19
i 9 9 9 Hospitals are poorly prepared to deal with these
ii 9 9 9 events,20 and there are significant operational chal-
iii 9 9 9 lenges to moving patients from hospital areas to the
9c 9 9 9 ground floor for evacuation21 or to makeshift landing
9d 9 9 9 zones on rooftops and in parking garages.13,22,23 Simu-
10a 9 9 lated vertical evacuations provide excellent examples of
10b 9 9 the challenges and technical considerations involved
10c 9 9 with this task21,24-26 (see e-Appendix 2 for an example27)
10d 9 9
Therefore, disaster plans that consider staffing require-
11a 9 9
ments for safe and rapid vertical evacuation are
important.
11b 9 9
12a 9 9 9
12b 9 9 9 Prepare for and Simulate Critical Care Transport
12c 9 9 9 3a. We suggest specialized care is resource intensive,
13a 9 9 and specialized ground and aeromedical teams may
13b 9 9 be required to ensure appropriate initial and ongoing
13c 9 9 care prior to and during evacuation.
13d 9 9 3b. We suggest preidentifying unique transport
resources that are required for movement of specific

populations, such as critically ill neonates, children, Centralized regional real-time tracking and commu-
and technology-dependent patients, at a regional nication are essential to match available facilities’
level. This information can then be used in real time resources to patients and minimize transportation
to match allocated resources to patients. duration and mishaps.7 Close coordination with
3c. We suggest conducting detailed and realistic specialty centers can minimize adverse outcomes
exercises that require ICU evacuation with local and during transport.36,40
regional ground and air transport agencies.
Multiple reports have described the hazards of planning Designate a Critical Care Team Leader
and conducting large-scale critical care movement at the 4a. We suggest the Incident Management System at
time of a disaster. Such efforts have been marked by the evacuating ICU hospital should support early
significant heroism but lack of resource coordination, and frequent communication between Incident
resulting in frequent reductions in patient monitoring Command and a designated Critical Care Team
and supportive care, which create safety concerns.13,14,16,22,28 Leader (CCTL) during an impending evacuation to
In overwhelming disasters, such resource limitation is provide close coordination and support of ICU
likely inevitable, but without pre-event planning and evacuation preparations.
preparedness, even small events can lead to patients 4b. We suggest the CCTL coordinating the critical
being hurt due to poorly allocated resources. Success- care evacuation should be responsible for (1) catego-
ful evacuation examples and expert consensus consis- rizing ICU patients by ICU resource requirement
tently cite early use of an Incident Command System to and (2) communicating these ICU patient resource
evaluate, communicate, and coordinate health-care and requirements with the Hospital Incident Command
evacuation requirements both within a hospital and and to any Regional or National Emergency Com-
between hospitals in a region, depending on the mand Center supporting hospital evacuation.
magnitude of the inciting event.7,29
4c. We suggest when preparing for and during an ICU
For health-care systems that do not use such coordi- evacuation, a primary role of the CCTL should be to
nating systems as part of their daily routine, detailed categorize each candidate ICU patient evacuee by
planning and realistic drills that use likely disaster (1) ICU resources required and (2) skill set of trans-
scenarios to test command and communication systems port staff required.
and that include the interaction of relevant hospital
personnel should be undertaken. Preparation and 4d. We suggest CCTLs and staff should receive special
transport of simulated patients using actual transport training, education, and practice on patient categori-
equipment increases the likelihood of successful zation and transport requirements.
individual performance and systemwide coopera- 4e. Expert providers from evacuation teams and
tion.10,24,30 Detailed recommendations and core compe- outside facilities, when possible through face-to-face
tencies for training are published elsewhere.31,32 communication on site, can help ensure appropriate
Common problem areas deserving additional focus transport planning and distribution based on avail-
include contingency plans when ICUs suffer significant able resources during transport and in receiving
infrastructure damage,3,19,20 timing of evacuation,2 facilities.
evacuation methods (including vertical evacuation Safe and timely ICU evacuation demands real-time
plans),21,24-26 patient distribution, and tracking. knowledge of the quantity, severity, and resource
The 9/11 disaster highlighted the paucity of pediatric intensity of multiple critically ill patients, often across
medical resources compared with available adult multiple units, and the special equipment and transport
services,11 and multiple accounts have detailed the needs they may require both during transport and at
inadequacy of disaster preparedness plans to address the receiving facility.7,21,23,41 The Critical Care Unit
the needs of neonates.33,34 Patients with extensive burns, Leader role as it existed in the Hospital Emergency
severe hypoxemic respiratory failure, and other Incident Command System was eliminated under the
advanced technology requirements for ongoing care (eg, new Hospital Incident Command System (HICS), but
intraaortic balloon pumps for temporizing cardiogenic Hurricane Sandy highlighted the difficulty in attaining
shock, externalized ventricular drainage for a severe situational awareness without this position.15,31 A Critical
subarachnoid hemorrhage) require specialized evacua- Care Unit Leader, with authority and communication
tion considerations and care during transport.31,35-39 links equivalent to an Inpatient Unit Leader, is an
essential direct point of contact for the Hospital Incident
Command Center during evacuation of critically ill
patients (see the “Surge Capacity Principles” article by
Hick et al42 in this consensus statement). We have
proposed using the nomenclature “critical care team
leader” to specifically designate this emergency role
with standardized responsibilities (e-Appendix 3).
As a leader of one unified critical care evacuation team
caring for patients distributed among many different
units, we prefer using the description of team leader to
avoid confusion. The CCTL should receive education
and training similar to other HICS leaders. Critical care
patients should be categorized (Fig 2) and iteratively
reevaluated and recategorized, when applicable, by
critical care resource, transport skill set, and transport
type.43 Of note, certain patients may be so subspecial-
ized (eg, a patient receiving centrally cannulated
venoarterial extracorporeal membrane oxygenation
[ECMO]), complicated, or severely critically ill that
direct communication between the CCTL and Incident
Command and regional specialty experts may be
necessary to determine the best clinical evacuation
and disposition. Evacuation drills should test the
communication structure among the CCTL, HICS,
and local or regional emergency operations center
(EOC).
Figure 2 – Example of a Critical Care Patient Categorization Checklist.

Initiate Pre-Event ICU Evacuation Plan We suggest that every ICU routinely categorize every ICU patient by
(1) ICU resource requirement, (2) transport skill requirement, and
5a. If pre-event hospital evacuation of critically ill (3) transport type. Ideally, this ICU patient categorization would occur at
patients might be required, then we suggest planning least daily during routine care and be entered into an electronic checklist,
for patient evacuation or shelter in place using an such as a whiteboard or portable computer device (with a backup paper
checklist). During a threatened or actual ICU evacuation, every ICU
Incident Command System should begin as early as would categorize its patients more frequently, even hourly. Categoriza-
possible. Possible strategies include shelter in place, tion should be performed by each unit leader most aware of patient
details (ie, ICU attending physician or ICU charge registered nurse) and
partial evacuation, or early evacuation, depending on then relayed directly to and verified by the Critical Care Team Leader.
the circumstances. Additionally, there should be a mechanism for electronically collating
these data so that both the Critical Care Team Leader and the
Some disasters, such as hurricanes, provide advance Incident Command can have real-time ICU situational awareness.
ALS 5 advanced life support; BIPAP 5 bilevel pressure ventilation;
warning and, hence, permit a pre-event evacuation that BLS 5 basic life support; CRRT 5 continuous renal replacement therapy;
can be planned and executed before the disaster occurs. ECMO 5 extracorporeal membrane oxygenation; EVD 5 external
Reports of actual hospital pre-event evacuations17,44 and ventricular drain; LVAD 5 left ventricular assist device; PEEP 5 positive
end-expiratory pressure.
the Hospital Evacuation Decision Guide published by the
Agency for Healthcare Research and Quality41 are
available to help hospitals to plan these movements. An the NYU Langone Department of Pediatrics following
Incident Command System structure should be acti- its Hurricane Sandy experience).
vated and evaluate existing hospital resources, including The CCTL should start evacuation planning well in
food, water, backup generators, staff, and equipment. If advance of the official decision to evacuate, starting by
power has been lost but the decision has not yet been requesting that each ICU team complete the Critical
made to evacuate, such as occurred in some hospitals Care Patient Categorization Checklist. Other responsi-
during Hurricane Sandy,15 we suggest a checklist bilities include identifying potential receiving hospitals
approach to ensure adequate ICU resources (see for critically ill patients and facilitating and coordinating
e-Appendix 4 for the Power Outage Checklist created by pre-event evacuation, if required. In some situations, the

decision about whether to evacuate is clear, but in management, which triggers a chain of requests for
other situations, multiple factors must be considered.45 regional, state, and federal assistance through the Federal
Similar to the power outage scenario, we also suggest Emergency Management Agency (e-Appendixes 6, 7).
a checklist approach to ICU evacuation when an Since its inception in 1984, the first NDMS response
ICU evacuation appears imminent (see e-Appendix 5 requiring large-scale regional patient evacuation
for the Evacuation Checklist also created by the followed Hurricane Katrina in 2005. Lessons learned
NYU Langone Department of Pediatrics following from that and other experiences contributed to contin-
Hurricane Sandy). uous process improvements evident in the responses to
5b. We suggest Hospital Incident Command during a Hurricanes Gustav and Ike in 2008 and the Haiti
threatened hospital evacuation should have a clear earthquake in 2010.
and direct mechanism for communication with local If federal aeromedical evacuation is required, the
governing bodies that control the timing and issuance Federal Emergency Management Agency requests
of regional evacuation orders. To prevent obstruction Department of Defense assistance for the Department
of ground medical transport during hospital evacua- of Health and Human Services-led evacuation. The US
tion, coordination with local government regarding Transportation Command is the Department of Defense
timing of recommendations for evacuation of the headquarters responsible for patient movement world-
general population may be required. Efficient ground wide.51 The US Transportation Command will direct the
medical transport of patients during a hospital patient to a properly staffed and equipped aeromedical
evacuation may be facilitated by providing a time team. Many very complex patients, though, cannot be
period for hospital evacuation prior to recommenda- moved en masse through this system. Hospitals should
tions for evacuation of the general population. prioritize private rotor and fixed wing aircraft and critical
Ground transportation difficulties during hospital care ground units for neonates and small pediatric
evacuation may occur during a natural disaster because of patients as well as larger children or adults with very
gridlock caused by evacuation of the general public.12,17 complicated management requirements. Nonspecialized
Air evacuation, therefore, is sometimes necessary.17 and nonseverely critically ill patients should be desig-
Coordination of hospital evacuation with local govern- nated for US federal evacuation.
ment orders for mandatory evacuation of the general The system in the United States is just one example
public might mitigate transportation problems for of a federal evacuation system that could be adapted
ground ambulances. The need for transport resources by other countries. e-Appendix 8 describes the
can also be optimized by pre-event disaster planning,15 coordination of international disaster emergency
triage and discharge of patients who do not require medical responses.
further hospitalization,46,47 use of alternative ground
transport modes in addition to medically configured Ensure Adequate Power and Transport Ventilation
vehicles,3,14 and transporting similar acuity patients in Equipment
groups.44
7a. We suggest surge ventilators with flexible electri-
cal power and oxygen requirements should be
Requesting Assistance for Evacuation available to support patients with respiratory failure
6a. We suggest during a disaster or pandemic that that can maintain function while either (1) sheltering
overwhelms local and regional resources and requires in place or (2) evacuating to an outside facility. These
large-scale hospital evacuations assistance, from ventilators should be portable, run on alternating
national and/or international government medical current power with battery backup, and have the
support and evacuation agencies should be requested. ability to run on low-flow oxygen without a high-
pressure gas source. Surge ventilators may be of
6b. We suggest the CCTL should be aware of the limited capability but should be able to ventilate and
process for requesting evacuation assistance and the oxygenate patients with acute lung injury or ARDS
resources available at a regional and national level. as well as airflow obstruction. This requires capability
In the United States, the federal government mobilizes to deliver a high minute ventilation, high flow, and
emergency medical resources through the National high positive end-expiratory pressure. They should
Disaster Medical System (NDMS).48-50 The hospital be safe (disconnect alarm) and relatively easy for staff
must request assistance through local emergency to operate.
7b. We suggest availability of adequate portable evacuate the entire hospital), may decrease the overall
energy and medical gas flexible ventilators that can time to evacuation.
provide accurate small tidal volumes or pressure 8c. In some situations, moving groups of similar-type
limits for the premature and neonatal patients patients to a single hospital entity may enable the
expected at designated hospitals (for instance pediat- sending hospital to provide staff to a single location to
ric centers or hospitals with a neonatal ICU). Special facilitate continuity of care and allow receiving
consideration should be given to creating a standard, hospitals to preplan to surge for specific types of
quickly accessible regional stockpile of mechanical patients and cluster disaster resources.
ventilators for evacuation of neonatal patients as it
8d. The most critically ill patients dependent on
may not be feasible for some nonpediatric centers to
mechanical devices for life support may, in some
have adequate numbers of portable energy and gas
conditions, be safely cared for with a shelter-in-place
flexible neonatal ventilators.
strategy if it is deemed the risk of evacuation is too
Available transport-type ventilators for evacuation of high.
patients with respiratory failure may come from local,
Priorities for evacuating patients are situation dependent.
regional, or national resources. Although functional
This includes priorities for which patients are evacuated
transport-type ventilators capable of operating on
first or last or which patients are sheltered in place.
battery power and with low-flow oxygen are optimal
during hospital evacuation in a disaster situation,52,53 bag In some situations, it may be favorable to evacuate less
valve ventilation is readily available and has been used ill patients first, and in other situations, it may be
over days to support patients, including neonates,54 favorable to evacuate the most critically ill patients first.
during prolonged hospital evacuations or when electri- The receiving facility should be capable of providing
cal power is lost or a compressed gas source is not care for the specific problems of patients. Selection of a
available.23 Disadvantages to bag valve ventilation of receiving facility may be done with one-to-one matching
intubated patients, however, are numerous and include of a patient with a receiving facility, but in some
requirement of a health-care worker to provide assisted situations, patients may be grouped for transport to a
ventilations, health-care worker fatigue during provi- receiving facility.
sion of assisted ventilations, inefficient use of oxygen The CCTL at the transferring hospital must assess the
resources, inadequate support of ventilation and clinical condition and ongoing care requirements of
oxygenation for patients with severe acute lung injury, critically ill patients and with local or regional Incident
and patient harm (barotrauma, pneumothorax, respira- Command, assess the capabilities of the hospital to
tory alkalosis, and accidental extubation).55 continue caring for these patients. Factors to consider
are infrastructure damage, medical supplies and staff
Prioritizing Critical Care Patients for Evacuation resources, anticipated additional patients and their
needs, and provider capability. Based on this assessment,
8. We suggest evacuation order and identification of the EOC leadership must work closely with transporta-
appropriate facility should be based on the following tion experts and available regional critical care units to
factors: match patient care needs to resources and services while
8a. In a time-limited evacuation, less critical minimizing transport distances and using all existing
patients can be evacuated faster and with fewer modes of transportation. In general, it is more common
resources per patient and, thus, may be moved to move critically ill patients first,3,21,56 and consideration
first in order to evacuate the most patients in the should be given to moving groups of patients of a
fastest time. specific specialty type together in certain situations.44
8b. When there is adequate time for evacuation, then If the disaster-affected hospital is able to deliver care, it
more critically ill patients may be moved first and in should provide medical supplies and assistance to rapidly
parallel with less ill patients. Similar acuity patients stabilize and prepare patients for evacuation while EOC
often use similar transport resources and strain the personnel are identifying transfer locations.5 For
same group of sending staff members. Thus, moving instance, burn surgeons and staff have been deployed to
both the less critical and more critical patients the incident hospital to ensure adequate patient resusci-
simultaneously in parallel, as compared with sequen- tation and management prior to evacuation for defini-
tially in series (when there is adequate time to tive burn care.36,57 In these situations, moving patients

with both more critical and less critical illness in parallel regional or national agencies are responsible for
after initial stabilization may shorten overall evacuation selecting appropriate receiving hospitals for evacuations.
time. When the risk of transport is deemed equal to or The responsible agencies vary from country to country.
greater than the risk of caring for a critically ill patient in For instance, in the United Kingdom, emergency
the disaster area, the patient may be cared for in place. evacuation and patient allocation during a disaster is the
responsibility of the National Health Service. In the
United States, an individual state government must
Critical Care Patient Distribution
request the NDMS to provide assistance with patient
9a. We suggest during isolated, small, or pre-event evacuation from hospitals.16,56 Even when these
ICU evacuations, CCTLs should coordinate with resources are deployed to assist with hospital evacua-
Hospital Incident Command and identify receiving tion, however, the CCTL at the referring facility may
hospitals for patient evacuation via the usual practice still be required to identify critically ill patients with
of provider-to-provider communication. life-support needs that may require specialty teams for
9b. We suggest during multiple-facility, large, or late transport, such as for patients with ARDS supported on
ICU evacuations, the usual provider-to-provider mechanical ventilation or ECMO.35,38,60-65
system of communication for identification of
receiving facilities should be augmented by other Preparing the Critical Care Patient for Evacuation
Regional or National Incident Management Systems.
10a. We suggest standardized preparation of critically
9b.i. Every hospital should be specifically affiliated ill patients should be performed prior to hospital-to-
with (and drill evacuation with) a Regional or hospital transfer, including initial stabilization,
National Command Center for such events. Regional diagnostic procedures, damage control procedures,
or National Command Centers may need to assume and medical interventions to address anticipated
responsibility for designation of the receiving facil- physiologic changes during transport.
ities for their patients.
A systematic approach to the decision to evacuate and
9b.ii. We suggest when a Regional or National prepare the patient for the physiologic stresses of
Emergency Command Center assumes responsibility transport will minimize the chance of complications in
for patient distribution, they should be responsible civilian,66 military,61 and neonatal critical care trans-
for identifying receiving facilities that match ICU port.40 The oversight of this process should be per-
patient resource requirements. formed by the CCTL at the sending hospital because
9b.iii. We suggest the Regional or National Emergency this individual is best qualified to determine the
Command Center should enlist assistance of regional appropriateness of transfer for patients.
specialist experts to assist in the above matching 10b. We suggest the transport team should provide
process for distribution of patients requiring highly the equipment used for transport to ensure compati-
specialized care among receiving centers. bility and familiarity during transport and retain
9c. We suggest assignment of transportation resources important resources at the source institution for
and lines of critical care patient evacuation should ongoing care of the remaining patients.
follow common existing referral patterns provided A risk of medical equipment malfunction exists during
receiving facilities retain adequate capacity to care for transport due to such factors as temperature and
these patients. barometric pressure swings, vibration, limited supply
9d. We suggest patients who require advanced of electric power and oxygen, and electromagnetic
specialty care should be directed to high-volume interference. A solution adopted by experienced military
centers and distribution take into account the capacity transport programs is to equip the transport team with
and resources required to provide ongoing care to a standard gear set.61,67 The transport team’s equipment
these patients. is applied to patients in the sending hospital, and
Hospital evacuations during disasters in the United patients are observed for stability prior to departure.
States often have been coordinated through existing 10c. We suggest evacuation planning and coordina-
referral patterns using referring physician-to-receiving tion should include the provision of additional expert
physician communication.3,17,21,44,58,59 However, this providers, staff, and equipment to assist in the
system may be overwhelmed. When this occurs, ongoing provision of care in situations where patient
volume, acuity, or nature of illness or injury exceeds complete medical record can be included. Electronic
the capabilities of the CCTL and staff. transfer may be through an intranet or by copying
A solution to relieve caregivers in a disaster area and patient information onto a USB flash memory drive
improve continuity of care is to insert teams that can or compact disk and transferring the information
manage these patients until they are ready for transport. with the patient ( see the “Business and Continuity of
This is most pertinent for highly specialized care not Operations” article by Tosh et al71 in this guideline).
typically provided at the sending facility. This model 11b. We suggest a paper medical record be required to
has been successfully used in disasters that produced travel with the patient because there may be no ability
casualties requiring burn care68 or ECMO.35 to send an electronic copy of the medical record, or
10d. We suggest utilizing a staging area for patients the receiving facility may not be able to read the
prepared and awaiting transport. This area should electronic format of the medical record. A backup
ideally be located near the point of embarkation and paper system may require (a) a printed copy of the
be staffed by medical personnel with training and expe- electronic medical record or (b) a handwritten patient
rience in critical care evacuation. These personnel should identification on a standardized patient tracking
be prepared to provide triage and perform ongoing form. Any paper system should include basic patient
medical care interventions prior to transport. The area identification, problem lists, and medications on
should have the capability for additional surgical and forms that travel with the patient.
medical stabilization pretransport if necessary. The number and rapidity of patient transfers that occur
One of the challenges of coordination of a multicasualty during a disaster places the patients at risk for medical
evacuation is managing the time between availability of errors. This risk can be mitigated by complete transfer
the evacuation vehicle and the readiness of patients for of the patient’s medical record.44 Electronic media
transport. This is best handled by setting up a staging area provide the most efficient means of transferring a large
staffed by medical personnel who are experienced in volume of data; however, effective electronic transfer
preparing critically ill patients for evacuation.69 This team may be limited by incompatibility issues between
sending and receiving hospitals or because of computer
must be trained and equipped to address the need for
system malfunction.21 For this reason, it is important to
issues such as central venous access, endotracheal intuba-
have a paper backup copy of the most essential patient
tion, pneumothorax decompression, and pain manage-
information for transfer. The most critical data to
ment.69 This approach to staging patients is standard for
prevent patient complications can be efficiently con-
multicasualty evacuation performed by the US Air Force
veyed with compact records, such as the HICS forms,
and was successfully used by the Australian Air Force
or even by writing on patient dressings.70
following a terrorist bombing in Bali, Indonesia.70
When possible, the most critical patients should be
Transporting Critical Care Patients to Receiving
staged directly from their bed in the sending hospital.
Hospitals
This can be accomplished by adding a transport staging
team to the hospital. Staging patients in place will 12a. We suggest transportation methods should
minimize handoffs and decrease their exposure to the prioritize moving the greatest number of patients as
transport environment. However, in some circum- rapidly and safely as possible to locations with
stances, it is necessary to create a staging area adjacent adequate capacity and expertise where definitive care
to an airfield that will serve as a point of embarkation. can be provided.
This may be required if there is a long distance from Rapid decompression of the disaster area provides
hospital to airfield, there are limited resources to trans- patients with access to more advanced care and makes
port patients from the bedside, or the staging area is resources in the disaster available for additional patients.
collecting patients from multiple hospitals for evacua-
12b. We suggest local evacuation of highest acuity
tion on the same vehicle.
patients to hospitals with additional capacity by
ground or rotary transport may be most appropriate
Sending Critical Care Patient Information With to minimize risk and reduce ongoing critical care
Patient demands at the incident facility.
11a. We suggest electronic transfer of patient infor- If high acuity patients overwhelm the incident hospital,
mation to the receiving hospital is optimal because a the most rapid means of decompression is to transfer

patients to the nearest hospital with adequate resources. casualties from the recent wars in Iraq and Afghanistan.51
This leverages existing transport teams and referral The availability of patient care equipment must also be
patterns. A successful model of this strategy is illustrated closely tracked. The same system that tracks casualty
in a report of the response to a casualty-producing movement can also be extended to include equipment
tornado.6 Importantly, this patient distribution needs to tracking.
be done in conjunction with the hospital’s Health Care 13c. We suggest tracking systems may be electronic or
Coalition or Regional Health Authority to ensure paper. In the event of complete power failure, how-
appropriate situational awareness. ever, a redundant paper system for tracking of
12c. We suggest alteration in the usual standards for patients and equipment should be performed by both
modes of transport may be required during a disaster sending and receiving hospitals, with communica-
where transport resources are overwhelmed and tions provided to the sending hospital and/or a
evacuation and transport of critically ill patients to a centralized coordinating center to confirm receipt of
receiving hospital ICU is required. the patients.
The usual standards for patient transport may not be 13d. We suggest evacuation drills should test tracking
achievable in a disaster. In this situation, vehicles that of patients and equipment both by electronic and
are not equipped for critical care transport, such as buses, paper systems.
trucks, and passenger cars,28 or nonmedically configured Electronic tracking systems have performed well in
helicopters3 may need to be used. Alternatively, if a disas- disasters and may be more efficient than paper-based
ter renders roads impassable, it may be necessary to systems.74,75 However, disaster conditions may cause
perform helicopter transports for patients who would failure of an electronic system, so disaster medical
otherwise be well managed with a ground ambulance. personnel must be prepared to deploy a paper or other
manual system.76 A large-scale exercise provides an
Tracking Critical Care Patients and Equipment opportunity to identify weaknesses and to train per-
sonnel to optimally use the system.44 Multiple models
13a. We suggest tracking of patients should com-
have been published describing successful evaluation of
mence in the sending clinical unit; continue to the
a tracking system.77-81
point of embarkation; and, if possible, continue to
the destination facility. Tracking of the patient and Areas for Research
equipment should commence prior to being loaded The published literature on evacuation of critically ill
onto the transportation. Minimum data sets for patients is extensive, but the level of evidence and
tracking should include the patient first and last generalizability of these case reports or single-institution
name, date of birth, medical record number or experiences are limited. The diversity of health-care
tracking number or triage number, time leaving systems and their surrounding regional resources, along
facility, transportation company name and trans- with the variation and complexity associated with the
port vehicle number, and expected destination and care and transport of critically ill patients following a
next of kin. variety of disaster events, makes it impossible to provide
13b. We suggest both the evacuating and receiving a series of systematic, evidence-based recommendations
hospitals should track patients and equipment. to guide universal preparations in this area. Future
In addition to clinical implications for tracking patients’ reports should make every effort to organize experience
whereabouts, it is equally compelling for family and using a current, standardized organizational framework
friends to know where their loved ones are being sent. offered by HICS and similar international guidelines to
An efficient mechanism is necessary to track patients facilitate synthesis of the information they provide and
from the point of initial triage back through the evacua- advancement and integration of the body of knowledge
tion chain to the final receiving hospital. This has been in this important and challenging area.
traditionally managed with casualty cards, but several All critical care providers should become familiar with
robust electronic systems have been developed and the newly proposed ICU Evacuation Timeline and its
demonstrated to be effective.72,73 The US Air Force three stages: (1) no immediate threat, (2) ICU evacua-
Aeromedical Evacuation System has developed a tion threat, and (3) ICU evacuation. We have made
web-based approach to provide in-transit visibility that several recommendations that dramatically increase,
has proven reliable in tracking tens of thousands of standardize, and codify the role of the ICU physician
leader during ICU evacuation in the role of the CCTL. External supporting organizations cannot recommend panelists or
topics, nor are they allowed prepublication access to the manuscripts
We have proposed two standard tools, including the and recommendations. Further details on the Conflict of Interest
CCTL Responsibilities and Critical Care Patient Categori- Policy are available online at http://chestnet.org.
zation Checklist. We have also presented three example Other contributions: The authors thank librarian Alicia Livinski,
tools, including (1) the Power Outage Checklist and MA, MPH, for assistance in the preparation of the evidence base for this
article and Scott Aronson of Russell Phillips & Associates, LLC, for
(2) the Evacuation Checklist (both from the NYU Langone evacuation expertise and contributions in generating research questions.
Department of Pediatrics) and (3) a vertical evacuation The views expressed in this consensus statement are those of the
author (A. S. N.) and do not reflect the official policy or position
simulation scenario. These first attempts are meant to of the Department of the Army, Department of Defense, or the US
spur creation of more finished documents adapted to Government. The opinions expressed within this manuscript are
solely those of the author (M. D. C.) and do not represent the official
one’s own facility and improved on for future directions. position or policy of the Royal Canadian Medical Service, Canadian
Finally, policy efforts must be made to enable regional Armed Forces, or the Department of National Defence.
patient information sharing both in real time during Additional information: The e-Appendixes can be found in the
disasters to enable effective regional critical care evacua- Supplemental Materials section of the online article.
tion and in postdisasters for event analysis to improve Collaborators: Executive Committee: Michael D. Christian,
MD, FRCPC, FCCP; Asha V. Devereaux, MD, MPH, FCCP, co-chair;
regional and hospital critical care evacuation processes. Jeffrey R. Dichter, MD, co-chair; Niranjan Kissoon, MBBS, FRCPC;
Lewis Rubinson, MD, PhD; Panelists: Dennis Amundson, DO, FCCP;
Conclusions Michael R. Anderson, MD; Robert Balk, MD, FCCP; Wanda D.
Barfield, MD, MPH; Martha Bartz, MSN, RN, CCRN; Josh Benditt, MD;
Successful ICU evacuation during a disaster requires William Beninati, MD; Kenneth A. Berkowitz, MD, FCCP; Lee Daugherty
active preparation, participation, communication, and Biddison, MD, MPH; Dana Braner, MD; Richard D Branson, MSc, RRT;
Frederick M. Burkle Jr, MD, MPH, DTM; Bruce A. Cairns, MD; Brendan
leadership by critical care providers. All critical care G. Carr, MD; Brooke Courtney, JD, MPH; Lisa D. DeDecker, RN, MS;
providers have a professional obligation to become COL Marla J. De Jong, PhD, RN [USAF]; Guillermo Dominguez-Cherit,
better trained, prepared, and engaged with the process MD; David Dries, MD; Sharon Einav, MD; Brian L. Erstad, PharmD;
Mill Etienne, MD; Daniel B. Fagbuyi, MD; Ray Fang, MD; Henry
of ICU evacuation to provide a safe continuum of Feldman, MD; Hernando Garzon, MD; James Geiling, MD, MPH, FCCP;
critical care during a disaster. Charles D. Gomersall, MBBS; Colin K. Grissom, MD, FCCP; Dan
Hanfling, MD; John L. Hick, MD; James G. Hodge Jr, JD, LLM; Nathaniel
Hupert, MD; David Ingbar, MD, FCCP; Robert K. Kanter, MD; Mary A.
Acknowledgments King, MD, MPH, FCCP; Robert N. Kuhnley, RRT; James Lawler, MD;
Author contributions: M. A. K. had full access to all of the data in Sharon Leung, MD; Deborah A. Levy, PhD, MPH; Matthew L. Lim, MD;
the study and takes responsibility for the integrity of the data and the Alicia Livinski, MA, MPH; Valerie Luyckx, MD; David Marcozzi, MD;
accuracy of the data analysis. M. A. K., A. S. N., W. B., R. F., S. E., L. R., Justine Medina, RN, MS; David A. Miramontes, MD; Ryan Mutter, PhD;
N. K., A. V. D., M. D. C., and C. K. G. contributed to the development Alexander S. Niven, MD, FCCP; Matthew S. Penn, JD, MLIS; Paul E.
of PICO questions; M. A. K., A. S. N., W. B., R. F., S. E., L. R., and C. K. G. Pepe, MD, MPH; Tia Powell, MD; David Prezant, MD, FCCP; Mary
conducted the literature review; M. A. K., A. S. N., W. B., R. F., S. E., Jane Reed, MD, FCCP; Preston Rich, MD; Dario Rodriquez, Jr, MSc, RRT;
L. R., and C. K. G. contributed to development of expert opinion Beth E. Roxland, JD, MBioethics; Babak Sarani, MD; Umair A. Shah,
suggestion; M. A. K., A. S. N., W. B., R. F., S. E., L. R., N. K., A. V. D., MD, MPH; Peter Skippen, MBBS; Charles L. Sprung, MD; Italo Subbarao,
M. D. C., and C. K. G. contributed to the conception and design, or DO, MBA; Daniel Talmor, MD; Eric S. Toner, MD; Pritish K. Tosh, MD;
acquisition of data, or analysis and interpretation of data from the Jeffrey S. Upperman, MD; Timothy M. Uyeki, MD, MPH, MPP;
Delphi process; M. A. K., A. S. N., W. B., R. F., S. E., L. R., and C. K. G. Leonard J. Weireter Jr, MD; T. Eoin West, MD, MPH, FCCP; John
developed and drafted the manuscript; and N. K., A. V. D., and M. D. C. Wilgis, RRT, MBA; ACCP Staff: Joe Ornelas, MS; Deborah McBride;
revised the manuscript critically for important intellectual content. David Reid; Content Experts: Amado Baez, MD; Marie Baldisseri, MD;
Financial/nonfinancial disclosures: The authors have reported to James S. Blumenstock, MA; Art Cooper, MD; Tim Ellender, MD;
CHEST the following conflicts: Dr Einav received grant money, Clare Helminiak, MD, MPH; Edgar Jimenez, MD; Steve Krug, MD;
royalties, and research funds for topics unrelated to this manuscript. Joe Lamana, MD; Henry Masur, MD; L. Rudo Mathivha, MBChB;
Dr Rubinson received grant money for two unrelated National Michael T. Osterholm, PhD, MPH; H. Neal Reynolds, MD;
Institutes of Health sponsored studies and makes public statements Christian Sandrock, MD, FCCP; Armand Sprecher, MD, MPH;
related to this topic. Dr Grissom receives grant support from the NIH, Andrew Tillyard, MD; Douglas White, MD; Robert Wise, MD; Kevin
National Heart Lung and Blood Institute as the principal investigator Yeskey, MD.
for the Utah Center in the prevention and early treatment of acute
lung injury. The remaining authors have reported that no potential References
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[ Evidence-Based Medicine ]

Evacuation of the ICU

e44S Evidence-Based Medicine [ 146#4 CHEST OCTOBER 2014 SUPPLEMENT ]

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Results or regional coordination.3 Important considerations in

e50S Evidence-Based Medicine [ 146#4 CHEST OCTOBER 2014 SUPPLEMENT ]

Figure 2 – Example of a Critical Care Patient Categorization Checklist.

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e56S Evidence-Based Medicine [ 146#4 CHEST OCTOBER 2014 SUPPLEMENT ]

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