Author(s): Fred Durso. Published on January 1, 2013.

Prepping for the Worst
Superstorm Sandy forced hospital evacuations and tested emergency procedures at health care facilities up and down the East Coast. Can new provisions in NFPA 99 help ensure things go smoother the next time the weather gets heavy?

Among the many hospitals affected by Superstorm Sandy was Hoboken University Medical Center in Hoboken, New Jersey. The storm flooded the hospital, destroyed costly radiological equipment, and forced the facility to close for two weeks. (Photo: AP/Wide World)

NFPA Journal®, January/February 2013 

By Fred Durso, Jr

Shortly after giving birth to her son, Cole, at New York University’s Langone Medical Center on October 29, the windows in Margaret Chu’s hospital room started rattling. Raging outside was Superstorm Sandy, which had already decimated areas along the Eastern Seaboard before hitting New York City. Chu tried to remain calm as the lights in her room flickered, then went out. Sandy had knocked out the power in lower Manhattan and created a storm surge that flooded the hospital’s basement, destroying the pumps that supplied fuel to the facility’s emergency generators on the 13th floor. Evacuation was imminent.


Medical workers assist a patient during the evacuation of NYU Langone Medical Center in New York City during Superstorm Sandy. (Photo: Corbis)


Lessons From Katrina
NFPA 99 Handbook outlines the emergency response to Hurricane Katrina in health care settings and the lessons learned from an operational standpoint.

Evac Standard 
An NFPA document in development will help guide large-scale evacuations.

 Are Operating Rooms Wet Locations (Jan/Feb 2010)
 Special Needs (Jan/Feb 2010)
 More Home, Less Nursing (Jan/Feb 2010)
 The Right Response (Jan/Feb 2010)

Assisted by hospital staff and emergency responders gripping flashlights, Chu descended 13 flights of stairs by foot as hospital personnel evacuated her newborn son. She noticed other new mothers and seriously ill patients — some attached to IVs and other medical equipment — being transported on plastic “med sleds,” used for emergency rescues, or in the arms of rescuers. “Everyone was pretty calm,” Chu told the Associated Press. “I would call it organized chaos.”

Rescuers traversed the darkened stairwells as many as 15 times to evacuate the hospital’s 325 patients, including babies from the neonatal intensive care unit who were attached to battery-powered respirators. The patients were then transported to 14 facilities in the Greater New York area. (Langone supplied these figures, but declined an interview with NFPA Journal for this story.)

According to the Greater New York Hospital Association, which helped coordinate the evacuations, about 6,000 people were evacuated from various health care facilities in New York City — nursing homes and adult day facilities among them — including five city hospitals.   “The fact that not one patient died or was seriously injured as a result is a testament to the incredible work done by teams of dedicated people who communicate regularly throughout the year on how to prepare for a host of potential emergency situations,” says Susan C. Waltman, the association’s executive vice president and general counsel. “Communication, cooperation, and collaboration are critical elements to the success of any emergency preparedness plan.”

Since evacuation is considered a worst-case scenario in health care settings, Superstorm Sandy has initiated discussions on shortfalls in emergency planning procedures at these facilities, similar to what occurred after Hurricane Katrina ravaged New Orleans and the Gulf Coast in 2005. Emergency management officials in cities impacted by Sandy and elsewhere are currently investigating the emergency power failures that occurred during the storm and how to avoid repeat occurrences. Health care experts interviewed by NFPA Journal note the importance of this issue, but also highlight an effective push for operational preparedness following Katrina that could explain why the New York evacuations went so smoothly.
For instance, the 2012 edition of NFPA 99, Health Care Facilities, has reinforced provisions that help identify hazard vulnerabilities and organize an emergency operations plan. The Joint Commission, which certifies and accredits more than 19,000 health care organizations in the U.S., has also bolstered similar provisions mirroring elements of NFPA 99. Long-term care facilities have developed more stringent mutual aid plans that include mandatory, emergency evacuation exercises.

“Some of the encouraging things I’ve seen [in hospitals affected by Sandy] is that in some situations where a facility lost power, they didn’t have to evacuate because they had plans in place for that event,” says Chad Beebe, director of codes and standards for the American Society for Healthcare Engineering (ASHE) and a member of the NFPA 99 Health Care Facilities Committee. “I think that’s a testament to their planning and the care for their patients. For those facilities that had to evacuate, that’s also a huge success story.”

Setting the standard
Following Hurricane Katrina, the NFPA 99 committee made a point to extensively update the code’s provisions on emergency management. Dedicating Chapter 12 to this subject, the 2012 edition of NFPA 99 includes a section on developing a hazard vulnerability analysis (HVA), which identifies threats — natural, manmade, or technological — to a facility and the impacts on patients and staff. The code also includes a list of mitigation strategies to eliminate the identified hazards.

Once an HVA is established, NFPA 99 recommends that health care facilities develop an emergency operations plan (EOP) to address critical functions within a facility during an emergency. A component of the EOP is providing the proper “resources and assets,” including vehicles to transport staff, patients, and equipment during an evacuation. Training staff on the EOP and testing the plan through functional or full-scale exercises at least twice annually are additional provisions aimed at keeping an emphasis on emergency planning.

“We also require annual updates to the HVA and EOP, which will play a huge role at health care facilities in New York and elsewhere,” says Jonathan Hart, NFPA staff liaison for NFPA 99. “They may have thought Sandy was a 100-year storm. Now that they know it’s a possibility, proper planning could help them prepare for the next one.”

Responding to an influx of new arrivals during a disaster — which occurred in New York City when 14 hospitals received patients from evacuated hospitals — is also covered in the code. The section on “surge capacity of victims” provides guidance on assessing victims and the risks they might pose to others.

The Joint Commission also saw a need to expand its guidance on emergency preparedness. The Comprehensive Accreditation Manual for Hospitals has beefed up provisions on emergency management that were modeled after Chapter 12 in NFPA 99. Prior to 2009, the requirements were a small subset of another chapter, says George Mills, director for the Commission’s Department of Engineering. “Everyone has been aggressive in getting [an EOP] built,” he says of the manual’s directive for facilities to organize a plan. “Our surveyors are finding that organizations have done a good job with preparation. There’s been a high level of compliance as far as developing these plans.”

Exercising the EOP is another Commission requirement that was invaluable when an EF5 tornado, one of the most powerful ever recorded, destroyed St. John’s Regional Medical Center in Joplin, Missouri, last year.  Mills says the hospital staff rehearsed a number of evacuation strategies two months before the tornado, but only one seemed most effective in that setting. “When it was time to evacuate, they maneuvered mattresses down the stairs with people on them, like a sled,” says Mills. “They evacuated 183 patients in 90 minutes with no injuries. An organization may ask, ‘What’s the value of an exercise?’ To evacuate this many people in a dark building … is a real testament to preparation.” 

Drill, baby, drill
Practice also makes perfect in nursing homes, assisted-living facilities, and other long-term care settings. Russell Phillips and Associates, a fire, code, and emergency management consulting firm, has been helping these facilities develop mutual aid plans since a 1982 arson fire that led to the evacuation of a 404-bed nursing home in Rochester, New York. Though there were no deaths from the incident, residents were temporarily misplaced during their relocation to area hospitals. A year later, Russell Phillips developed a mutual aid plan that included protocols for tracking patients.

The company has expanded its plans over time to include guidance on securing emergency resources and assets. “Supplies, staffing, equipment, and transportation are things you need to support your infrastructure if you’re isolated,” says Scott Aronson, principal with Russell Phillips. “Ninety-nine percent of the time, you can avoid an evacuation if you provide what’s necessary.” 

Evacuation, however, is unavoidable in certain situations, which is why Russell Phillips encourages health care facilities to conduct full-scale drills addressing a series of disasters. (Mock evacuation exercises at nursing homes in Massachusetts this summer, for example, involved an impending hurricane.) The drills tend to cover similar components, including rapidly assessing the facility’s status, mobilizing resources, determining where a patient or resident could be transported, managing and informing family members of the actions being taken, and tracking patients. To date, mutual aid plans and mock evacuations have been conducted at more than 950 long-term care facilities in Connecticut, Massachusetts, New York, and Washington. This year, Russell Phillips plans to bring another 91 nursing homes in Rhode Island on board.

Aronson admits emergency preparedness has rightfully received its fair share of attention and support, but notes some challenges. “The dollars set aside for preparation have been reduced substantially and continue to be reduced,” he says. “The big challenge will be if monies will be diverted internally to support longer-term infrastructure hardening, or will people look at this more short-term and say, ‘Let’s just have a good evacuation plan?’ I’m not sure where the dollars will go.”

In the meantime, health care experts are continuing to analyze data in the wake of Superstorm Sandy. ASHE is surveying up to 500 hospitals affected by the storm to assess emergency management plans and the buildings’ electrical systems. “I firmly believe that [NFPA 99] is adequate as is,” says ASHE’s Beebe, “but we’re willing to find a validation of that through this research” — and, if necessary, areas where the code can be expanded, too.

Lessons From Katrina

The following excerpts are from the supplement “Health Care Emergency Management Response and Recovery: New Orleans,” which can be found in the 2012 edition of the NFPA 99 Handbook, available for purchase at The supplement outlines the emergency response to Hurricane Katrina in health care settings and the lessons learned from an operational standpoint.


Hurricane Katrina struck the Louisiana and Mississippi Gulf Coast on August 29, 2005, as a strong Category 3 hurricane. The hurricane was the single most costly hurricane to strike the United States. Prior to Katrina, health care planning stressed staying in place rather than evacuation as a strategy. This proved to be a fatal mistake in some cases, primarily in long-term care facilities.

Review of what went wrong
Those responsible for implementing a disaster plan in advance of a storm will be criticized for either evacuating or not evacuating. An evacuation of the magnitude faced during Katrina had never been exercised or completely planned. Moving patients away from a catastrophe is possible given time, planning, and resources. Housing, food, clothing, employment, schooling, and health care needs for displaced patients of a major metropolitan area are beyond the scope of most current plans.

Evacuating patients is one of the most hazardous undertakings that a facility can face. The physical trauma and mental stress of moving [can be] sufficient to justify the rejection of an evacuation. However, as the organizations learned the consequences of staying, a point arrived at which the patients were at greater risk by remaining in place.

Recommendations: Health care evacuation
The largest improvement that can be made is identifying the exact point at which evacuation of health care facilities is mandated. Evacuating is extremely costly and dangerous, as is the decision to stay and weather the storm. At some point, the balance tips, and evacuation must be implemented. A pre-approved checklist of balance points for staying or evacuating is currently not part of disaster planning.

Experience is the only reliable guide [to help determine whether to stay or to evacuate]. Those who are on life support, are violently aggressive, or are prematurely born may die if removed from the health care environment for evacuation. Those same patients may die if they are not evacuated and support services fail. Both of these actions were taken during Katrina. The relative comfort of the patient, however, can be dramatically improved when full service is available. Therefore, evacuation must be completed early enough to provide critical care patients the time to be transported with proper support to ensure their survival, and, at the end of their journey, their comfort and care.

The element of evacuation in disaster response should be drilled and practiced to provide the administrator and physicians with an understanding of when a balance has been reached or exceeded.

Evac Standard 
An NFPA document in development will help guide large-scale evacuations

At its August 2012 meeting, NFPA’s Standards Council approved the development of a new standard that will provide guidance on essential elements of mass evacuation. The Council’s decision followed a summit last February where key stakeholders — including NFPA, the National Governors Association, and the International Association of Fire Chiefs — addressed mass evacuation and recommended that NFPA take the lead in developing a planning guide for emergencies.


The as-yet-untitled standard will provide emergency responders, elected officials, emergency management officials, and emergency preparedness planners with criteria on evacuation stages and roles. Health care facilities will also benefit from this guidance, says Orlando Hernandez, the NFPA staff liaison overseeing this project. “Let’s say there’s a train derailment, and you have chemicals leaking and a plume heading toward the direction of a hospital,” says Hernandez. “The standard will provide guidance on sheltering in place or evacuating. Officials will give them that notification so they can place their own plan into action.”

NFPA has secured a technical committee chair for the new standard and is in the process of reviewing applications for other committee members. The Standards Council will review all applications at its March meeting.

— Fred Durso, Jr.