Coordinated response. North Shore-LIJ's system-wide emergency management practices dated back to 1997, when the company centralized emergency preparedness and issued a directive that emergency preparedness training be part of leadership core competency. ^[13] The company adopted the Hospital Emergency Incident Command System (HEICS), a variant of the Incident Command System (ICS) developed by the federal government. ICS was a standard method of managing emergencies that unified and organized a community's or organization's response. The system aimed to bring all available resources and people into a common organizational structure, coordinate actions across jurisdictions and organizational boundaries, and provide a common terminology.

ICS provided a clear chain of command in an organizational structure:

• An incident commander
• Public information, liaison, and safety and security officers
• Logistics, planning, finance and operations units ^[14]

North Shore-LIJ modified the HEICS into a Network Emergency Incident Command System (NEICS). "Scale is important," says Mark J. Solazzo, executive vice president and chief operating officer. "We can direct resources for the betterment of the whole system."

Thats important because when you make decision like an evacuation... youre able to do it in a way that is much more coordinated and effective than if you were in a stand-alone institution. So having thousands of hospital beds at your disposal instead of 450 or 900 is important. We have somewhere in the neighborhood of 6,000 hospital beds these days. Having all of the transport services available weighs in your decision. Having home care available [and] having the ambulatory sites available [are] all important in your decision-making process. ^[15]

Patient safety. All hospital incident response planning methods put patient safety above all else. The challenge in evacuations was weighing the risks. In the case of an earthquake or fire, the decision could be straightforward. Often there was no question about the need to move patients out of the facility. In preparing for a hurricane, however, hospital officials had to weigh the probability of a hazard -- that a storm would hit a given area and that it would result in damage to a facility -- against the certain hazard of moving patients. "It's all about minimizing risk to the patient: the risk of transfer versus the risk of staying," says Solazzo. He explains:

No administrator wants to move vulnerable patients. Were talking about sick, sick people. Were talking about our most vulnerable: surgical cases, medicine cases, intubated patients, babies that are sick. When you move a patient in that kind of state, you risk their lives. Is there greater risk to leave a patient in that environment and weather the storm? Or do you need to move that sick patient? Is anyone going to die because of the decision you made? Youll never know if you saved a life because of it, but you will know if you hurt somebody.

The challenge for an incident commander was understanding that you never have enough information but you still have to make a decision, says Solazzo. In the case of hurricanes, wind speed was an important factor in timing evacuations. It was unsafe to operate ambulances in winds over 45 mph. This meant administrators had to make an evacuation decision in enough time to complete the evacuation before winds reached that intensity. This put the decision point at 48 hours or more before the hurricane was forecast to make landfall, long before forecasters could be certain about the hurricane's track. Solazzo explains:

You just have to make that decision based on the best information that you have available. Emergency management is about making decisions with incomplete information. Youll never have all the information you want or have it with a degree of confidence that will make you rest easy. You just dont. [But] you still have to have the ability to make a decision, because the lack of action is a decision.

Beyond safety, moving patients also imposed emotional and logistical burdens on the patients' families, says Solazzo:

Theres a lot of issues when you move patients. Not only the clinical issues, but also the psycho-social issues. If youre moving a sick patient from Staten Island University Hospital to Lenox Hill, youve got a whole lot of family members to worry about. How are we going to get in touch with them in a timely [manner], make certain they know where their loved one is, make certain they know that theyre safe? And then how do we help them see that patient?

Ripples. Burdening families was just one consequence of evacuating a hospital. The patients being evacuated and the loss of services from the closed hospital were a wave that spread through the surrounding community's healthcare system. "Theres such a ripple effect when you evacuate hospitals," says Romagnoli.

You burden the other hospitals nearby whove taken on those patients. And then were going to have the amount of injuries and sheltering needed from the storm or the event, which is going to put a larger burden on them.

James Romagnoli details who is affected by a hospital evacuation:

This ripple effect forced a high degree of cooperation among otherwise competing healthcare systems. "What we do with one hospital will significantly affect another hospital five miles away," says Solazzo. He explains:

In disasters theres no competition. If my competitor health systems and institutions dont do well, that has a negative impact on my institution during a disaster. So we all want to make certain that everyone does well during these things.