Hurricane Decision: Evacuate or Shelter in Place

Use a time-phased decision, not a yes-or-no vote at noon.

Define triggers: a mandatory evacuation order is a lagging indicator; the hospital should act on its own hazard analysis. Worst-case surge inundation of the ground floor and flooding of the access road are triggers for evacuating at-risk patients, because the hospital cannot safely shelter if the ground floor floods and the switchgear is in the basement.

Calculate evacuation time: 10 hours for 8 ICU patients once transport arrives, plus dialysis and behavioral health patients. The storm is 36 hours away, but tropical-storm winds may close roads in 12-18 hours. Start now.

Sequence: evacuate the most vulnerable first (ventilated ICU, dialysis, patients who cannot be moved later) to pre-identified receiving facilities, then decide whether the remaining patients can shelter safely.

Coordinate with the county EOC for transport assets, destination capacity, and road status. Do not assume ambulances will be available later.

Communicate with staff, patients, and families; activate the incident command system; document the rationale and the triggers used.

Hybrid option: evacuate the ventilated and dialysis patients and shelter the rest only if the building can maintain power, water, and access above flood level. With switchgear in the basement, that assumption fails, so a full evacuation should be considered.

Reasoning: the plan says shelter in place, but plans are assumptions, not commands. The CEO's job is to match the decision to the hazard timeline and document why the plan was or was not followed.

If patients remain, verify these before landfall:

• Supplies: 96 hours of water, food, medical supplies, oxygen, and medications, plus pharmacy and blood bank reserves.
• Power: generator fuel for 96 hours, load test, and a refueling plan. If switchgear is in the basement, flood protection or relocation is required; otherwise sheltering is not credible.
• Staffing: sufficient relief, sleeping arrangements, credentialing of volunteers, and dependent-care plans for staff.
• Communications: redundant systems such as satellite phones and radios, EHR downtime procedures, paper records, and patient tracking.
• Clinical: dialysis, ventilator, and oxygen plans; isolation and infection control; behavioral health safety.
• Security: access control, traffic management, and protection of supplies.
• Evacuation contingency: if conditions worsen, the hospital must be able to evacuate later, which may be impossible after landfall.

Reasoning: the 96-hour standard is a planning benchmark, not a guarantee. The switchgear location and access-road flooding are the weak points that determine whether sheltering is safe; if either fails, the decision should shift toward evacuation.

Under the CMS Emergency Preparedness rule for hospitals (42 CFR 482.15), the hospital must have an emergency plan based on an all-hazards risk assessment, policies and procedures, a communication plan, and training and testing. Training must be documented. Testing requires two exercises per year, at least one community-based, unless the hospital activates its plan for a real emergency, which can count.

After the event:

• Conduct an after-action review with staff, the EOC, and receiving facilities; identify what worked and what failed, such as transport timing, fuel, switchgear, and communication.
• Update the risk assessment, plan, and procedures; revise memoranda of understanding with receiving facilities and transport vendors.
• Train staff on the changes and document the training.
• Report to the board and safety committee, and share lessons with community partners.

Reasoning: the surveyor will ask whether the plan was followed and whether it was updated after the exercise or event. A real activation with a documented critique and revised plan is stronger evidence than a binder that was never used.