Getting Baby Out

Developing an emergency preparedness plan for evacuation of a neonatal intensive care unit often is looked at as a necessary step to successful hospital-wide preparedness, but one that we hope never actually becomes a reality. Evacuation of this patient population only occurs in the most severe situations and carries the potential to compromise patient safety.

Speed, safety and coordination are hallmarks of a successful NICU evacuation. Taking a minimalist approach to the equipment taken with patients ensures they can be evacuated in the least amount of time. Any additional equipment required should be moved either before (prepositioned) or after the safe evacuation of the patient.

The patient population (Level 1, 2 or 3) will determine the needs and acuity of tiny patients. The equipment needs of a Level 1 nursery are minimal: blankets to ensure warmth, medications and charts. A Level 3 nursery would require much more extensive equipment: ventilation, chest tube management, I.V. medications, oxygen and thermal support.

Once the minimal equipment needs have been determined, clinicians need to decide how they will safely evacuate patients.  Currently, four primary methods are available for evacuation of neonates:

One-by-one: Carrying patients out one at a time allows trained staff to closely (visually) monitor the patient, but requires multiple trips by staff and that dedicated staff remain at the receiving unit and in the evacuated unit until all patients are gone. Given the increasing age demographics of healthcare providers, multiple trips by staff increases the potential of falls or stress-related health issues and with it, risks to the patients being evacuated.

Kangaroo Method:  Use of an evacuation apron allows one staff member to evacuate two to three patients and remain with them in the evacuation receiving area. The staff person has the added weight of the patients but has their hands free as they travel. However, the patients cannot be visually monitored during transit due to the design of the apron. Some of the challenges encountered are that the patients must rely on being carried, cannot be left until a dedicated bed is found, and there must be trained staff in the receiving area. It is not an optimal choice for the acutely ill patient requiring closer visual monitoring. Depending on the acuity of the patients, the ability of the caregiver performing the transport to respond to the needs of the patients is very limited. The risk of stress-related falls in staff evacuating the patients also is a very real concern. Staff have limited ability to protect patients during a fall and attempting to protect them may result in the caregiver suffering injury, creating additional issues.

Stretcher Method: An evacuation stretcher allows two staff members to evacuate three to six patients rapidly and reduces the possibility of falls due to its speed limitations. It allows patients who are acutely ill to be more closely (visually) monitored.  The biggest downsides of the evacuation stretcher are its lack of maneuverability (such as through the tight turns in a stairwell), the challenge of keeping the stretcher level and the number of staff required to implement it. It also requires an increased manpower commitment that may not be available in all units or may be dependent on the type of MCI.

Tracked Extraction Carriage: The extraction carriage is a tracked carriage that allows one attendant to evacuate up to six patients.¹ It can carry an oxygen cylinder and is narrow enough to navigate both hallways and doorways. The carriage is equipped with a failsafe reversible brake handle that engages the brakes anytime the attendant lets go of the handle. Additional safety is provided by a security strap that attaches to the attendant, preventing the carriage from getting away from the attendant while she navigates stairs. The unit can be mounted to a wall for immediate access during an emergency. The carriage also features headrests to safeguard the patients head, neck and spine and, once at the chosen evacuation receiving area, the patients can be contained in the carriage which then serves as a multiple patient bed.

The final consideration in developing a preparedness plan for NICU evacuation is coordination of the receiving area. Selection of candidates should be based upon both vertical and horizontal evacuations. Electronic monitoring capability, medical gas delivery, heat and electricity, access to medical and pharmaceutical supplies, and site security all are essential components of a viable evacuation site. But the design/layout of the receiving area is dependent upon the type of nursery being evacuated (Level 1, 2 or 3). As part of your preplanning assessment, you must review each possible receiving area and compare its features to a list of your essential "must haves."

Once you have developed the list of your proposed evacuation sites, you then must assess your evacuation routes. In this, simplicity and speed are important features. Choosing the shortest distance with the least number of doors, stairways or complex turns improves both speed and safety. Getting there is half the job. 

After selecting a final receiving area, determine where alternate supplies can be acquired and the availability of environmental support (heat and light)/control (as hypothermia is a very real concern with neonates). This information should be incorporated into both the written and practiced plan.

Site security also should be a very real consideration because the ability to monitor and control the comings and goings of personnel and visitors becomes nearly unworkable. Security of your final receiving area should be reviewed, tested, and critiqued as part of a preparedness plan. Missing patients are always a concern during mass casualty incidents and the disappearance of a neonate is even more of a concern due to their small size and portability.

Laminated copies of planned routes should be part of your evacuation packs to ensure that the route is readily available and easily understood during an evacuation.

Dave Swift, RRT, is campus coordinator, professional practice respiratory therapy, at Ottawa Hospital - Civic Campus, Ottawa, Ontario, Canada. He is also respiratory therapy lead/subject matter expert, for the National Office of the Healthcare Emergency Response Team, Public Health Canada. If you'd like to submit a question about disaster response, email dswift@ottawahospital.on.ca or kmastiff@magma.ca.

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