Anatomy of an evacuation: a major fire forced this New Jersey nursing facility to trigger its disaster response plan sooner than it expected.

When the Pine Barrens in southeastern New Jersey caught fire in May, residents and staff of Genesis HealthCare's Southern Ocean Center in adjacent Manahawkin were faced with the alarming mission of evacuating the facility. But with a solid emergency plan in place, Southern Ocean Center's staff who able to safely transfer its 119 residents to other Genesis centers and a local shelter. "I've never been through anything like this in my 17 years as a healthcare administrator," says Administrator Shelley Wyatt of the coordinated effort that yielded valuable lessons about the importance of a careful response plan.

As the fire began in the late afternoon of May 15, columns of smoke rose above the Pine Barrens, with the fire eventually consuming more than 19 square miles and closing several local highways. Local Emergency Management authorities decided to evacuate the area's northwest neighborhoods first, leaving Southern Ocean Center unaffected during the first few hours of the fi re. However, the fire could not be contained, and the threat of shifting winds caused the authorities to expand their evacuation area to include Southern Ocean Center.

The Center's adventure began with staffers implementing the facility's emergency response plan and readying residents for the daunting task of a potential evacuation. "One of the first things we did was shut down all the HVAC units to minimize the smoke entering the Center," explains Wyatt. "Then, in preparation for an evacuation, we separated each patient's chart, medications, and a change of clothing into packages that were secured to each patient's wheelchair."

Many nursing centers prepare for evacuation with the scenario of evacuating to just one location such as a local nursing center or shelter, with a few of the most critical transferring to a hospital. In this case, all three area nursing facilities faced a similar evacuation and the hospital was on standby to evacuate, as well.

As 19 of the most medically complex patients were being transferred to an available facility a safe distance away, Center personnel made plans for others to be transferred to one of 30 other Genesis centers in New Jersey. However, local EMS commandeered all transportation and made the remaining 100 residents, as well as the residents and staff of two other area nursing centers, transfer to the local high school.

The situation at the local high school was less than ideal for providing care, even though Southern Ocean staff had brought enough food and medical supplies--and smiles--to keep patients comfortable. The facility was allocated only 10 cots and the use of only one handicapped bathroom, so the organization knew it would be better for everyone to get their patients to Genesis nursing centers. Overnight, while staff cared for patients, Wyatt worked with Genesis regional employees to find suitable transport from the Philadelphia area to move patients from the high school to the centers.

As the sun rose the day after the evacuation, a caravan of wheelchair vans arrived at the evacuation center. After a brief argument with a state EMS staffer who wanted to commandeer the vans, Southern Ocean Center started moving the frailest residents. Luckily, as part of the emergency plan, multiple sets of driving directions were kept in a folder at the main reception desk. These directions proved invaluable as ambulance crews from Philadelphia moved patients from the high school to other Genesis centers. "Preparing detailed directions to multiple facilities in advance helped our transport process run smoothly," notes Wyatt.

Timely communication was imperative during the Southern Ocean Center crisis. When the Center determined it would need to evacuate and call for support from Genesis regional management, administration discovered that the area emergency team was at a Philadelphia Phillies baseball game that evening. However, the team quickly came together and activated its emergency operations center in Kennett Square, Pennsylvania. A conference call line was established and kept open for nearly 24 hours so that anyone involved with the evacuation could call for updates. At the start of the evacuation, family members were notified of their loved one's location and were kept in contact over the course of the evacuation. At the high school, officials allowed Wyatt to set up a command center to provide a central location for communication.

Throughout the process, staffers discovered that their advance preparations had proved vital to preventing any communication breakdown. "I would recommend that all administrators purchase a police scanner, should telephone or cell phone lines become unreliable," advises Wyatt. "During our crisis, limited information came from emergency responders, and another means of receiving information would have been helpful." She has also since purchased a portable crank generator with universal cell phone charger adapters.

"Our staff were amazing during the crisis," says Wyatt. Staffers executed their respective jobs virtually without a hitch, and Wyatt was impressed with the suggestions and proactive approach employed by the entire team on duty at the time. "Everyone was thinking on their feet--their contributions exemplify the professionalism and skill of our staff," she adds.

One lesson learned was the value of preserving a number of staff should the crisis continue for a prolonged period. Naturally, in a crisis, employees may call up and offer their help for the immediate future. A successful alternative approach used by Southern Ocean Center was to ask some of the staff not to report to the center immediately.

Because the administrator, director of nursing, and many of the staff were awake for nearly 36 hours, it was crucial that a reserve of fresh nursing and support staff be available when residents were transferred to other facilities and then returned home. (All available Genesis physicians, respiratory therapists, and clinical managers evaluated residents as they arrived at alternate centers and then on return to Southern Ocean Center.)

Interestingly, Genesis HealthCare had recently engaged employees in a corporate disaster preparedness program, but administrators of Southern Ocean Center had never imagined the timeliness of their training. "In the wake of Hurricane Katrina, Genesis, like most long-term care providers, has been looking to increase emergency preparedness capabilities," says Lisa Salamon, director of public relations for Genesis HealthCare, who also heads up the firm's emergency preparedness program. Salamon, who worked in nuclear power generation for 10 years before joining Genesis, notes that over the past year the focus has been to develop regional and corporate emergency support teams that could handle catastrophic events. In fact, a company-wide emergency drill was scheduled for the week after Southern Ocean's wildfire evacuation. "We have since postponed the drill to give us time to incorporate the lessons learned from Southern Ocean Center," Salamon notes. A new company-wide drill is scheduled for September.

During disaster preparedness training, employees are given templates for emergency plans that can be customized with local information. Individual nursing centers also engage in evacuation drills that provide important practice for a real emergency. "Over the next year," says Salamon, "our goals are to issue an updated 'all hazards' emergency plan template to our centers, and to provide them with realistic scenarios to further train the staff and help staff develop family preparedness plans."

Southern Ocean Center's experience with the wildfire evacuation proved invaluable in reinforcing the need for advance planning. Through careful organization, teamwork, and clear communication, administrators and nursing staff executed an evacuation that allayed patients' fears and seamlessly attended to their medical needs. Despite the obvious stress of the situation, patients handled the situation with cooperation and ease.

Upon returning home after a day in a local shelter and a transfer to a Genesis sister skilled nursing facility, residents of Genesis' Southern Ocean Center were greeted with balloons, banners, and applause. After a thorough check-in, it was with much celebration that administrators, nursing staff, and residents breathed a sigh of relief that the evacuation went according to plan with virtually no problems. Wyatt and her team surveyed families and residents upon their return to the Center and received excellent ratings; families were comforted by the strong communication during the crisis and by the fact that their loved ones went to other Genesis centers and were able to be followed by their regular caregivers. Southern Ocean Center didn't, however, forget those in the community who helped them successfully manage the crisis. The Center ran a "Thank You" advertisement in local papers to acknowledge all those who helped keep its residents and staff safe.

Southern Ocean Center's experience with this crisis proves that with proper training, clear communication, and strong support from the community, nursing centers can safely evacuate and care for their residents, even in the most difficult situations.

Dennis Gregory is Vice-President, Operations, for Genesis HealthCare. He can be reached at [phone]. Shelley Wyatt, Administrator, can be reached at [phone], and Lisa Salamon, Director of Public Relations, at [phone]. To send your comments to the author and editors, e-mail [e-mail].

RELATED ARTICLE: Lessons Learned

* Be prepared for none of your transportation contracts to work.

* Have your medical director accompany you to the mass evacuation center.

* Have a clear triage process for patients.

* If at all possible, evacuate to other care center(s).

* Invest in a police scanner and cell phone chargers that work without electricity.

--Dennis Gregory

RELATED ARTICLE: How Assisted Living Should Prepare for Disaster

Assisted living regulations vary widely from state to state, and official involvement in a facility's disaster preparedness can vary, as well. No matter if your facility reports to a licensing office or not, preparation is the key when it comes to disasters. Depending on the size of the facility, the administrator can designate an individual to coordinate all the facility's disaster's preparation. However, every staff and resident in your facility should be prepared for a disaster.

What follows are checklists to ensure disaster preparedness at the organizational, staff, and resident levels. At the organizational level:

* Provide instructions, assign duties, and assign posts for when a disaster strikes.

* Maintain first aid/CPR training.

* Train staff to assist with medical, physical, or mental needs of residents--for example, provisions for oxygen and wheelchairs.

* Review disaster preparedness and evacuation plans with staff at least once year, and with new hires.

* Post contacts and numbers of those who should be notified in an event of an emergency.

* Ensure availability of disaster-trained staff on all shifts.

* Conduct safety inspection checks throughout the facility at least once a year and keep an updated log of the inspections.

* Provide staff with formal disaster training--for example, from the American Red Cross, emergency management agencies, or the local fire department.

* Provide staff fire extinguisher training. Get them familiar with the classes of extinguishers and what each one of them does.

* Conduct at least annual drills with staff and residents, and document all drills that take place.

* Have a system in place to notify families of a disaster, particularly of any relocations that may occur.

* Have an in-house disaster team, headed by the administrator, with key staffers.

* Have professional counselors on standby for residents, families, and even your staff.

Emergency Supply Kits

Emergency supply kits should contain:

* Water: A gallon of water per person per day.

* Food: At least a three-day supply of nonperishable food.

* Miscellaneous items such as first aid kits, nonprescription medications, tools, blankets, a flashlight with extra batteries, and a National Oceanic & Atmospheric Administration weather or AM/FM radio with extra batteries.

Relocation Plans

The best way to prevent any problems of relocating residents is to have a relocation facility ready for any disaster. When a disaster occurs at your facility, you need to coordinate with your relocation facility and let staff there know how many people are coming and what special needs may need attention. It's always good to have more than one relocation facility available in times of a disaster. Always keep an updated list of these relocation sites in your disaster plan. Include procedures for evacuating, methods of transportation, meeting special needs en route, and working with coordinators of these facilities.

Written Plans

All emergency-related disaster procedures and evacuation plans should be in writing and distributed or otherwise made available to staff and residents. Evacuation and meeting maps should be posted throughout the facility, as well. It's a good idea to work with local police and fire departments, hospitals, and emergency services so they can get familiar with your facility and residents. You may want to provide them with the following information:

* Contact names and numbers of staff in charge of decision making

* Number of staff and residents throughout the facility, including numbers for nights, weekends, and holidays

* Number of residents with disabilities and their locations

* Disaster plans/procedures of your facility, with evacuation maps

* List of all relocation sites, coordinator names, and how residents will be transported to these sites

* List of staff training qualifications and specific responsibilities

* Documents of disaster drills conducted

* Strong and weak points discovered in any drills, emergency responses, and disaster plans

* Meeting areas for residents and staff

* Arrangements for meeting with police and fire departments, emergency services, and hospitals to discuss preparations for a disaster

Resident Information

Residents should be provided the following:

* Information on the kinds of disasters in which the facility is prone

* Location of nearest emergency telephone--post any emergency numbers near all these phones

* Nearest exits

* Nearest fire pull stations

* What to do if residents smell smoke or see a fire

* Where to meet when the facility is evacuated 

* How families will be contacted (and make sure staff keep updated contact information for all families)

Involve residents with disaster drills. Meet with residents and ask them questions about disaster planning and evacuation procedures.

Edward Brachman is Vice-President of Emergency Management International (USA), Inc., based in Rhinelander, Wisconsin. For further information, phone [phone] or e-mail [e-mail].