Disaster Preparedness

in NICU’s
Fernando Moya, MD
Medical Director
Betty Cameron Children’s Hospital
CEO
Coastal Carolina Neonatology and Coastal
Children’s Services
 Objectives and Disclosures
Objectives:
• To describe two contrasting NICU evacuations
• To enumerate lessons learned from these events
• To suggest a path forward for NICU’s within NC
to assist each other when confronted with disaster
and potential need for evacuation

Disclosures:
• Have been involved in three partial or major NICU
evacuations….and have no desire to do it again
• I am not an expert on the subject
 Evacuation of NICU at MHCH in Houston
Tropical Storm Allison
• On June 2001, tropical storm Allison dropped
more than 37 inches of rain over Houston.
• There was catastrophic flooding of the city and
Texas Medical Center. At MHCH electrical power
was lost around 1:40 am on June 9th, and at 3:30
am all power was lost.
• This became an emergency, unplanned evacuation
• The NICU (84 bed capacity) had 79 infants,
including 20 on ventilators/CPAP. It was located
on the 7th floor of a 10-story building. The Heliport
was on the roof top.
Cocanour C, Arch Surgery 2002
Images of Texas Medical Center
 Evacuation of NICU at MHCH in Houston
• The decision to evacuate the sickest patients at the
main hospital was made at 10:30 am; at 14:00 it
was decided to evacuate all patients.
• In NICU, a decision to evacuate ALL infants was
made about 9:00 am and a staged evacuation plan
was established in a NICU command center. This
interacted with the main hospital command center.
• Preparations were made to care for less ill infants.
• Seventy-eight infants were safely evacuated to 22
NICU’s throughout southeastern Texas. One baby
with severe BPD and frequent need for CPR died.
• All infants had been evacuated by about 22:00.
Cocanour C, Arch Surgery 2002, Moya F, Pediatr Res 2002 (abs)
Evacuation of NICU at MHCH in Houston
Salient Patient Care issues:
• Most equipment used in NICU care runs on
electricity, with few exceptions, i.e. bubble CPAP.
• Also, most of this equipment had limited or no
battery power capabilities.
• With loss of power, compressed air was also lost.
Hence, oxygen became the only gas source.
• Temperature support was a major challenge.
• Providing care in the dark or semi-dark was
extraordinarily hard and required more hands
• There was no or limited ability to order fluids,
medications or laboratory tests.
Cocanour C, Arch Surgery 2002, Moya F, Pediatr Res 2002 (abs)
Evacuation of NICU at MHCH in Houston
Salient communication issues
• All telephone lines were lost and cell phone usage
was restricted.
• Thus, internal and external communications were
extremely difficult.
• There was no listing of phones of other NICU’s,
both locally and at state level.
• There was no EMR then. Therefore, we produced
a hand-written one-page summary to send.
• The rest of the hospital sent actual charts….and
lost many.

Cocanour C, Arch Surgery 2002, Moya F, Pediatr Res 2002 (abs)

Evacuation of NICU at MHCH in Houston
Follow up issues
• Care was not over once babies were evacuated.
• The following day a NICU office with extra phone
fax lines was established in an attending’s home.
• Personnel were dispatched to various NICU’s to
support care.
• Many infants needed to be transported again to
a different NICU due to a mismatch in acuity.
• An accurate log with each infant demographics,
contact information and final destination was kept
and adjusted daily.
• The multifaceted impact of this disaster for infants,
families, providers and institutions was huge.
Cocanour C, Arch Surgery 2002, Moya F, Pediatr Res 2002 (abs)
Hurricane Florence
Evacuation of NICU at BCWCH in Wilmington
Hurricane Florence
• In September 2018, hurricane Florence aimed
at the NC coast and hit Wilmington. Its potential
trajectory was anticipated for days.
• NHRMC established a command center ahead of
time and teams were formed, i.e. storm, recovery.
• NHRMC leadership allowed the medical leadership
of BCWCH to determine the need for evacuation.
• The NICU had a low census of 36 infants, including
9 on Ventilators/CPAP.
• These infants were sent to 3 different NICU’s.
• Also, women with pregnancies <36 weeks were
transferred and the hospital closed for deliveries.
Evacuation of NICU at BCWCH in Wilmington
Hurricane Florence
Communications
• An email communication chain using PQCNC
was initiated, complemented by phone contact.
• Key parts of the medical record as well as order
sheets were printed ahead of time.
• A plan was established to communicate in case
the internal system failed.
• Families were notified of their infant status, i.e.
staying or transfer, and were given the option to
evacuate.
• Close contact with Obstetrics and MFM was kept.
Evacuation of NICU at BCWCH in Wilmington
Hurricane Florence
Patient care issues
• Transferring sicker infants allowed the acuity of
remaining infants to markedly decrease.
• This also reduced the need for x-rays, lab. tests,
pharmacy and other ancillary services.
• Enough personnel and providers were staged to
provide care for NICU infants during and after the
storm.
• Main power was lost but emergency power was
sustained. Cell phone service, internal and external
miraculously was never lost.
Evacuation of NICU at BCWCH in Wilmington
Hurricane Florence
Aftermath
• The hospital experienced relatively minor damage.
• Maintaining the supply chain was difficult given
that flooding essentially transformed Wilmington
into an island for days.
• NHRMC eventually transferred adults in need of
intensive care.
• NICU personnel were in “shelter-in-place” for 5-6
days; “recovery” providers rotated within this period.
• Many activities were planned and done to maintain
morale of personnel, who did not know about their
families or potential property damage.
 Storm Team

Recovery Team
 Disaster Preparedness
Key Challenges of NICU Population
• Usually the ICU with the largest number of patients
• Very vulnerable population:
• Respiratory support (need for O2, blenders)
• Monitoring
• Thermoregulation
• Often complex nutritional support
• Much of the equipment used in NICU’s is not
battery operated
• Transport equipment is complex and usually
in restricted numbers
• Dependence on parental support, consent

Phillips P, Neonatal Network 2012; Femino M, Pediatr Emerg Care 2013

 Disaster Preparedness
Key Components of Plans for NICU Evacuation
• Clear Command Structure
• Administrative
• Medical-Nursing
• Resources
• Personnel
• Enough key personnel
• Establish team rotations
• Lodging and food
• Supplies
• Medications (Pyxis access)
• Fluids and Nutrition (BM storage)
• Lighting
Espiritu M, Pediatrics 2014
 Disaster Preparedness
Key Components of Plans for NICU Evacuation

• Resources (Cont’)
• Communication and Medical Records
• Redundant and back up systems
• Printed key information
• Equipment
• Emergency power
• Battery operated
• Emergency gas supplies
• Transport equipment

Espiritu M, Pediatrics 2014

 Disaster Preparedness
Key Components of Plans for NICU Evacuation
• Situational Awareness
• Other ICU’s within the institution
• Obstetric, MFM Services
• Internal priorities within NICU
• Regional Coordination
• List of regional NICU’s and census
• Availability of Transport Resources
• Flexibility and Adaptability
• Involvement of multiple institutions
• Establish priorities within the institution
• Ability to improvise
Espiritu M, Pediatrics 2014
 Disaster Preparedness
Key Components of Plans for NICU Evacuation

• Family Care and Involvement

• Communications and consent
• Participation in direct care
• Follow up plans
• Alternate plans if NO communication

They are often also affected by the disaster

Espiritu M, Pediatrics 2014

 Disaster Preparedness
Future Directions for NICU’s in NC
• NICU’s throughout the state should help each
other to develop disaster plans.
• We should create and update a roster of all
NICU’s in the state, to include number of beds,
maximum “stretch” capacity, level of care, and
very importantly, contact information. Also, the
names of Medical Directors and the NICU’s
transport capability should be described.
• To ease communications, email and
message groups should be created and updated
periodically.
 Disaster Preparedness
Future Directions for NICU’s in NC
• Potentially, a small multi-disciplinary group of
experienced health care workers from NICU’s
within NC could constitute a working group
focused on how to further statewide plans:
• Facilitate creation of disaster plans in
all NICU’s in the state.
• Ability to share EMR (Care Everywhere).
• Periodic review of emergencies that may
prompt statewide involvement.
• Interaction with other bodies involved in
care of children in NC (i.e. Pediatric Society).
 Disaster Preparedness
Lessons Learned
• Disasters of various types and magnitudes will occur
• Some will allow further planning while others will
need to be faced with, ideally, pre-established plans
• NICU’s concentrate the largest number of
vulnerable patients that depend on technology,
hence power, for their care.
• Thus, plans to address disasters in NICU’s need to
be established and ideally rehearsed periodically.
• No matter how well organized an institution, a unit,
a group of individuals might be, there will always be
a need for flexibility, adaptation and improvisation.