2019 Searles Valley Earthquakes
Understanding Healthcare Facility Administrator Decision-Making and Information Needs
Publication Date: 2021
Following no-notice disasters, healthcare organizations must make important decisions about evacuation, closure, reentry, and reopening. These decisions have substantial impacts on the ability of disaster-affected communities to access healthcare. Yet, there is limited evidence on information considered by healthcare administrators when making such decisions. We conducted key informant interviews with eight healthcare administrators and leaders involved in decision-making about the closure, evacuation, reopening, and/or reentry of healthcare facilities following the 2019 Searles Valley Earthquakes. Interviews were transcribed and thematically analyzed. Due to the national holiday, only three facilities, which operate 24 hours daily, were open when the foreshock and main event occurred on July 4 and 5, 2019, respectively. They reported challenges accessing and synthesizing information to inform evacuation. Closed facilities reported varied plans and preparedness for evacuation. Facility administrators reported strong consideration for employee and patient safety during evacuation and reentry decision-making. They described specific information, tools, and resources that could enhance preparedness and decision-making following future earthquakes. Findings from this work can inform healthcare and public health organizational plans and policies for evacuation, closure, reopening, and reentry decision-making.
Ensuring the healthcare system’s continuity during and after a disaster is a critical component of community resilience. In addition to damage that objectively prohibits the use of healthcare infrastructure, subjective decisions related to facility closure, evacuation, reopening, and reentry made by healthcare administrators have the potential to hinder healthcare access in disaster-affected communities. This is especially true in rural communities with limited or centralized healthcare infrastructure, where the closure of a single facility can disrupt access for hundreds of miles. Yet, there is limited evidence on information considered by healthcare administrators during evacuation, closure, reopening, or reentry decision-making processes. The majority of the existing evidence is limited to evacuation-related decision-making during hurricanes with advance warning and is focused on acute care hospitals. As such, additional research is necessary to understand decision-making following no-notice events (e.g., earthquakes) and across different components of the healthcare system (e.g., clinics, urgent care centers, dialysis providers and home health organizations) critical to healthcare system community resilience.
On July 4, 2019, 10:34 a.m. Pacific Time, a magnitude 6.4 foreshock hit Ridgecrest, California and the surrounding area. Thirty-four hours later, a magnitude 7.1 earthquake struck 7 miles north (United States Geological Survey, 20191). These two events were the most significant of the 2019 Searles Valley Earthquake sequence and provide a unique opportunity to better understand factors influencing closure/reopening and evacuation/reentry decision-making during a no-notice earthquake across different types of healthcare facilities. After the first earthquake, the Ridgecrest Regional Hospital evacuated all patients to surrounding hospitals. The emergency room was kept available for triage and for patients in active labor, with operating rooms available for caesarean sections. The hospital fully re-opened on July 8 (Ridgecrest Regional Hospital, 20192).
The objective of this project is to collect data needed to understand healthcare administrators' decision-making processes when assessing whether to evacuate, close, or shelter-in-place, as well as to reenter or reopen their facilities following closure or evacuation in the aftermath of this earthquake sequence. Guided by the Protective Action Decision Model, this research will explore considerations that impact healthcare facilities’ decision-making following no-notice earthquakes.
This event provided a unique opportunity to learn about information considered by hospital and healthcare facility administrators during evacuation and reentry decision-making. In response, this research asks:
- What information was considered by Ridgecrest healthcare administrators when they made decisions about facility closure, evacuation, reopening and reentry? How did factors considered vary between different healthcare facility types?
- What information, tools, or resources would facilitate improved decision-making by healthcare administrators following no-notice events?
The existing healthcare evacuation decision-making literature is largely focused on meteorological events with advance warning (McGinty et al., 20163, 20174; Shoaf et al., 20185). These studies found that much of the process is “intuitive” in nature, but depends on experience in previous events, knowledge of the building or facilities, and availability of information regarding the approaching storm (McGinty et al., 2016, 2017; Shoaf et al., 2018; Ricci et al., 2015). This research has been focused on hospitals and largely excludes outpatient healthcare facilities, as well as residential long-term care facilities.
While there are studies about the impacts of evacuation of hospitals following earthquakes (Schultz et al., 20036; Sternberg et al., 20047), there are no studies of the decision-making process healthcare administrators use to decide whether or not to evacuate a hospital after an earthquake. As the average number of reported injuries in earthquakes worldwide (1980-2009) has been estimated at an average of 3,499 per event (Doocy et al., 20138), decisions regarding healthcare facility closure, evacuation, reopening and reentry have the potential to significantly impact a community's capacity to care for the injured, as well as those needing medical care unrelated to the disaster. This study expands the existing literature on hospital evacuation decision-making during and after advance-notice events by: incorporating and comparing decision-making in healthcare facilities other than hospitals; focusing on decision-making considerations following no-notice events; and understanding considerations in facility closure, reopening, and reentry decisions.
There are a number of theoretical models describing the evacuation decision-making process of individuals, households, and organizations (Dash & Gladwin, 20079; Lindell et al., 200510). The Protective Action Decision Model (PADM) provides a valuable theoretical framework regarding protective-action selection (Lindell & Perry, 201211, 199212) that can be applied to healthcare facility closure, evacuation, reopening, and reentry decision-making. According to PADM, the decision-making process includes: risk identification (“Is there a real threat I need to pay attention to?”, e.g., damage to facility, impacts to health and safety of patients and employees); risk assessment (“Do I need to take protective action?”, e.g., are the impacts of the damage or to staff health and safety sufficient to warrant action); protective action search (“What can be done to achieve protection?”, e.g., evacuation, shelter-in-place); protective action assessment (“What is the best method of protection?”, e.g., considering tradeoffs, develop an adaptive plan to evacuate, shelter-in-place, reenter, and/or reopen); and finally protective action implementation (“Does the action need to be taken now?” e.g., determine when to evacuate) (Lindell & Perry, 2012).
Understanding information considered for risk identification, risk assessment, and protective action assessment is particularly important in the context of a healthcare evacuation decision-making in the context of no-notice events, where healthcare administrators have to quickly consider the relative risk and opportunity costs of evacuation and shelter-in-place decisions. Improved knowledge of factors that influence these decisions may enhance our ability to predict and improve healthcare system capacity following other large-scale earthquakes, as well as inform the development of tools (e.g., decision aids) and training that can enable healthcare administrators to make informed, risk-based decisions.
We identified potential participants through publicly available contact information for healthcare facilities listed on the California Department of Public Health’s Cal Health Find Database (California Department of Public Health, 201913). Within Ridgecrest, there are 16 licensed healthcare facilities, including one general acute care hospital, two ambulatory surgical centers, three community clinics, four rural health clinics, two skilled nursing facilities, one dialysis clinic, one hospice, and two outpatient/speech pathologist clinics (California Department of Public Health, 2019). The Ridgecrest Regional Hospital system is the primary health provider in Ridgecrest and seven of the sixteen medical facilities in town fall under its jurisdiction. The hospital’s Chief Executive Officer is the decision-maker for these seven facilities. Prospective participants were sent an initial hard copy invitation letter and then contacted by email and phone to set up interview dates and locations.
Damage to water supply pipes in one Ridgecrest healthcare facility. The building oscillated during the earthquake as designed, but the fixed plumbing, which was not designed to move, sheared. ©Stephanie Meeks, 2019
Three members of the research team (KP, MM, MS) traveled to Ridgecrest, CA from January 26 to 29, 2020 where they conducted eight in-depth semi-structured interviews of healthcare administrators or leaders involved in decision-making about closure, evacuation, reopening, and/or reentry of their facilities following the 2019 Searles Valley Earthquakes. Two of these interviews were conducted by phone by one member of the team (MS). Interviewees had authority for or were significantly involved in decision-making for 10 of the 16 healthcare facilities. In addition, we also interviewed a representative from the county health department, which has oversight for emergency medical services. Detailed notes were taken during interviews, and with interviewee permission, interviews were audio recorded and professionally transcribed for data analysis.
A semi-structured interview guide (Appendix 1) was adapted from prior work completed by co-investigators (MM and KS) based on the research questions and PADM. Specifically, our interview questions examined: which individuals were included in the decision process; what information was sought; where was the information obtained from; how did decision makers weigh the risk of evacuation vs. shelter-in-place; and what information did decision makers consider when determining whether to reopen or re-enter their facilities? A preliminary codebook of primary and sub-codes based on the research questions, prior work and expected products was developed. Additional codes were added following a data familiarization process where interview notes and transcripts were read in their entirety. Codes were given a definition, along with directions and examples of when the code should be applied. Two investigators (KP and MS) coded two transcripts and compared coding to assess inter-coder reliability. Discrepancies were adjudicated through consensus building discussion. Each of these investigators then independently coded three transcripts each. Key themes were summarized in alignment with the research questions and theoretical model (Miles et al., 199414).
The study was determined to be exempt by the University of Washington and University of Utah’s Institutional Review Boards (IRB).
Ridgecrest healthcare administrators discussed decision-making considerations and information, tools, and resources that were beneficial or needed when making decisions about evacuation or reopening/reentry (Table 1). The first earthquake, a magnitude 6.4 foreshock, occurred at 10:34 a.m. on July 4th, which is a U.S. national holiday. Only the regional hospital, the distinct-part skilled nursing facility—which is embedded within the hospital, and the free-standing skilled nursing facility were open and forced to consider evacuation of patients. The other healthcare facilities in Ridgecrest would have reopened the following business day, but remained closed to assess damage. As a result, they were also closed when the second earthquake, a magnitude 7.1 quake, struck on July 5th. Informants from these other facilities discussed existing plans for evacuation, had the earthquake occurred while they were open, and their decision-making processes around reentry and reopening.
Table 1. Information Sources and Factors Considered in Decision-Making
Informal building safety assessments made by healthcare facility leadership and/or staff
Formal building assessments made by designated agencies
External agencies reporting information about future earthquake risk
Internal information about patient census and acuityNews and social media
Environmental hazardsContinuity of operations
|Protective Action Assessment||
Preparedness: plans and training
Continuity of operations
Staff wellbeingIncomplete information
Following the earthquake, the facilities that were open reported relying on informal building safety assessments conducted by their leadership or staff to identify building safety impacts that would impede their operations. It was noted that the reliance on self-assessments was inherently self-limited; while nonstructural impacts (e.g., cracks in drywall) were obvious, some facilities did not have the capability to assess whether or not there was structural damage that compromised the building itself.
Key informants reported concern about additional earthquakes. They reported receiving information from external agencies about future earthquake risk, which proved to be secondhand and ultimately incorrect. It was mentioned that misinformation was circulating on social media, although social media was not used to inform decision-making directly.
Internal information about the number and status of patients was also discussed in decisions to evacuate. For instance, open facilities reported considering information about their facility census and patient acuity.
Key informants described receipt of information about the first earthquake, the possibility of a second large earthquake, and the ongoing disaster response from a variety of sources, including the Ridgecrest Police Department, the hospital, and the USGS. One informant recalled hearing CNN and other news outlets’ claims that the first earthquake was only a foreshock, and others reported accessing information from social media.
Most informants reported actively looking for reliable information about the possibility of another earthquake. Some informants reported that direct phone calls and texts with friends, family, colleagues, and community contacts played a role in decision-making. However, one informant described some negative impacts of multiple information sources:
It was an information overload, I felt. But I'm very connected to the city website, the city Facebook page, the police department Facebook page. Those were excellent sources of information. I found everything they posted to actually be really credible and had sources cited and wonderful things. The USGS was the main thing that people were citing, which was good. There was a lot of false information out there floating around on Facebook, which I think created a lot more panic.
Facilities reported both informal, internal building safety assessments and more formal, external safety assessments that guided their decisions to reopen. External consultants, expert building inspectors, and/or state and city engineers were consulted for building damage, utility disruptions, and equipment safety. Two informants mentioned that they performed visual inspections of their building on their own and decided that it was safe to stay or reenter since there was no visible structural damage. One of these informants also sought confirmation from a non-engineering external source. One informant discussed the importance of having specialists assess their equipment (e.g., radiation) because they could appear to be working correctly even if they are not, and this could result in harm to staff and patients.
In assessing risk to their patients and facility, key informants reported assessing their patient acuity, visual structural impacts, and nonstructural impacts. Ultimately, risk assessment was grounded in perceived ability to safely continue to provide care. No visual structural impacts were detected by any open facility. However, several nonstructural issues were observed by the hospital staff. For instance, water damage caused by broken pipes was observed, causing concerns about mold and Legionnaire’s disease. Utility disruptions (e.g., power) and their impacts to patient safety were also discussed as important considerations. Exposing patients (e.g., those who had been evacuated to tents outside one facility) to extreme temperatures for prolonged periods due to absence of air conditioning was reported as an important consideration. Concerns about environmental hazards/heat exposure were compounded by incomplete information about timeliness of ambulance arrival for patient transport.
Key informants reported considering structural impacts to their building. They also reported considering ongoing utility interruptions, including those related to medical gas, power, and water. A couple of facilities were concerned about affirming or ensuring sterility and cleanliness (e.g., from dust or water damage). A couple of facilities also reported considering risk of prolonged disruption to access to care among their patients as part of their risk assessment.
Protective Action Assessment
In determining whether to evacuate or shelter-in-place, facility representatives reported impacts to patient safety as their primary consideration. For instance, one key informant mentioned that ultimately it was most important to get the patients evacuated so they could receive better care at another facility not impacted by the earthquake.
While facilities reported having plans to guide decision-making, with rare exception, they did not report directly consulting these plans during the event. Instead, they relied on their training, experience developing the plan and in prior earthquakes, and situational awareness about the event at hand to guide their decision-making. For example, the hospital’s prior horizontal evacuation exercises gave them confidence in their ability to successfully relocate patients within their facility.
The jurisdiction’s rural setting also impacted decision-making. Key informants reported considering impacts of their decision-making on access to care given their geographic remoteness. Respondents expressed concern that if their facilities closed, members of the community would lack nearby timely access to medical care. Informants reported that the earthquake caused rockslides and resulted in road closures inhibiting strike team arrival in Ridgecrest and, in turn, delaying ground transportation-based patient evacuation. One informant indicated that changes in perceived patient frailty and long evacuation times encouraged more rapid evacuation approaches (i.e., initiating helicopter evacuations).
While not explicitly discussed as a factor that directly impacted evacuation decision-making, key informants noted that there were financial impacts of their decision to evacuate. While evacuation resources ordered by emergency medical services professionals through the Medical Health Operational Area Coordinator were paid for by the government, evacuating facilities became financially responsible for any evacuation resources procured outside of this process. One key informant noted that while they stood by their decisions to secure air transport for particularly frail patients, it could have bankrupted their company.
Key informants discussed staff wellbeing as another consideration during evacuation. They described potential inconveniences to staff related to working at different locations away from their families. Notably, facilities that were not open during the earthquake reported checking on staff.
Incomplete information also led to more precautionary decision-making. For instance, one key informant discussed uncertainty around the integrity of the building without external expert confirmation. This, coupled with the information about the potential for a larger earthquake, influenced their decision to evacuate. This key informant reported that had they better understood the integrity of their building, they likely would have made a different evacuation decision. But by the time the inspectors arrived, the evacuation was already underway.
Concerns about their ability to provide care in facilities damaged by the earthquake and/or water damage, as well as the ability to provide safe and effective care while experiencing a medical gas disruption, were discussed in the context of reopening/reentry decisions. One key informant reported that they would not reopen until all services were restored, which required repair to the medical gas system and other inspections. A key informant from an affected facility said: “That was our biggest thing. Not having med[ical] gas is, you really shouldn’t be doing surgeries if you don’t have the access to the med[ical] gas that you need. So that was one of our biggest things.” However, a key informant from another facility reported that repairs necessary to reopen were delayed because contractors were afraid the building was unsafe and were unwilling to enter it.
Staff mental health and wellbeing impacts were also described in the context of reentry and reopening decisions. For example, in one facility, concerns for staff and their emotional wellbeing reportedly delayed decisions to reopen. One facility reported that at least two members of their staff had permanently relocated because of emotional impacts of the earthquakes.
Continuity of care also was reported to have influenced decisions to reopen. One key informant mentioned that many patients rescheduled existing appointments following the first earthquake, which helped inform the decision to remain closed until all healthcare services (i.e., operating services) could be restored. On the other hand, other facilities reported interest in reopening to provide access to time-sensitive or critical care for their patients or community, as there was no comparable care access nearby. Ridgecrest’s geographic isolation was reported as a major driver to get expert inspections completed in order to reopen the health care system and reestablish healthcare in the area.
Information, Tools, and Resources for Decision-Making
The need for improvement in communications for no-notice events was consistently discussed. This included communications between medical facilities, as well as with police/fire, county-level EMS, and the local military base. For example, key informants reported unclear communication about the arrival of ambulances for patient evacuation hindered response.
Some level of misinformation was described by the majority of key informants. For instance, key informants reported confusion over terminology for evacuation processes. For example, key informants discussed lack of understanding about the definition of catalogued resources (e.g., strike team), and discussed the need to use plain-language terms (e.g., mutual assistance) in future incidents.
The need for healthcare administrators to have established relationships with and contact information for local and county counterparts was described. Suggestions to develop relationships included attending meetings and getting involved in multiple healthcare coalitions, since regional healthcare access patterns did not necessarily align with county boundaries.
Tools and Resources
Due to Ridgecrest’s geographic isolation, decision-makers reported having to rely on local resources for the first few hours after the first earthquake. For some key informants, the fact they live so far from other cities meant they expected that they would be on their own in a disaster. When deciding whether or not to evacuate, key informants reported that it was critical that they have access to needed transport. For the main medical provider, there was a problem with the ambulances taking a long time to arrive to evacuate patients. One key informant described their experience:
So, the end result is we had patients that started getting hotter and hotter. We had coolers we brought out, and by the time it got to 2:00 in the afternoon—and this is despite being told multiple times the ambulances are on the way; it’s two hours from Bakersfield to here—it kept getting changed. “Well, they just left Bakersfield.” And then two hours later, “They just left Bakersfield.” It’s like, “Well, how long does it take to leave Bakersfield?” And so by the afternoon, I had to make the unenviable decision to move the med/surg patients back into the outpatient pavilion so they could be cool.
When asked about the types of equipment that would be useful for future no-notice events, most key informants mentioned that since the earthquake, they had stockpiled various items they wished they had during the emergency. Other desirable items mentioned by at least one key informant included grab-and-go kits; tents that could accommodate a power source for light and air conditioning; vests that could be worn by staff to identify them to patients during an evacuation and post-evacuation; food and water for patients/staff; radios; and a designated Hospital Incident Command System (HICS) radio channel. One key informant that had to deal with a larger evacuation said, “I needed a door stopper,” and reported frustrations with door stoppers being against safety codes. This key informant reported having to get patients through several fire safety doors that would not remain open because the fire alarm had been triggered. Another key informant mentioned that having a full list of equipment within the medical facility that was easy at hand would have been helpful in making decisions about next steps. Making sure all employees have ready access to disaster response plans was also mentioned. A mobile command post is also being purchased/built that can be used by all of the county in a similar event.
Understanding the factors considered in the healthcare administrators’ decision-making process around closure, evacuation, reopening, and reentry can help predict and improve healthcare system capacity following other large-scale earthquakes, as well as inform the development of tools (e.g., decision aids) and training that can enable healthcare administrators to make informed, risk-based decisions. This study expands the existing literature on hospital evacuation decision-making during and after advance-notice events by incorporating and comparing decision-making in healthcare facilities other than hospitals; focusing on decision-making considerations following no-notice events; and understanding considerations in facility closure, reopening, and reentry decisions. Findings from this work can inform the development of strategies that healthcare organizations and public health agencies can incorporate into plans and policies to inform such evacuation, closure, reopening, and reentry decision-making.
This exploratory, qualitative case study has several limitations. First, interviews occurred almost seven months following the earthquakes. As we asked facility leaders to recall the factors they considered in their decision-making immediately following these events, it is possible that time or hindsight introduced bias in their recall. Second, as Ridgecrest is a small rural community with a largely centralized local healthcare system (i.e., several licensed facilities are part of the same organization with consolidated decision-making authority), we were only able to successfully recruit eight key informants in our study. It is possible that key informants who agreed to participate in our study, or the facilities they represent, are systematically different from those that did not. Moreover, because the event occurred over a holiday weekend, only three facilities were open and had to engage in evacuation decision-making. Given the limited number of healthcare decision-makers in Ridgecrest, combined with the limited number of facilities that engaged in decision-making relevant to this study, information presented herein is largely descriptive in nature, and is not necessarily representative of theme saturation. While we believe the insights generated from this important research are illustrative of evacuation and reentry decision-making in remote communities with limited resources following a major earthquake, we recommend additional research about healthcare evacuation decision-making following other earthquakes and no-notice events across additional rural communities.
This research has demonstrated that there are commonalities and differences in evacuation decision-making and information needs following notice and no-notice disasters (McGinty et al., 2016, 2017; Shoaf et al., 2018). Through future work, we hope to explore decision-making information needs and preparedness among hospitals exposed to and experienced with response to a variety of hazards. As an immediate next step, the faculty PIs of this research have submitted a proposal to the National Science Foundation’s Humans, Disasters and the Built Environment program to understand public health and emergency management decision-making and information needs, as well as community-level health and wellbeing impacts, following the 2019 public safety power shutoffs in California.
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