Disaster Planning for Obstetrical Services

Purpose Statement

The purpose of the Stanford Disaster Planning Toolkit website is to share with the general obstetrical community, work that has been done at our facility. Stanford Health Care hospitals consist of 2 tertiary centers, which include a high-risk obstetrical center and level three neonatal care unit.

Although all hospitals are at risk for events that may necessitate evacuation, Stanford Health Care resides within multiple geologic faults increasing our risk of earthquakes and the need for total hospital evacuation and shelter-in-place scenarios.

The toolkit provided in this website addresses the issues of evacuation of labor and delivery and antepartum units as well as shelter-in-place for actively laboring patients. Though not yet employed in an actual disaster, these tools have been used in full unit simulations of disaster training allowing for adjustment and refining of all the instruments provided.

Below you will find generic forms that will allow each hospital to customize it to their needs.

Future plans are to complete a similar toolkit for evacuation of postpartum patients and a toolkit for surge protocols.

Our goal in providing this website is to gather feedback from facilities that use any parts of the toolkit so that we can refine and improve our tools further, and to use this website as a central repository where the entire obstetrical community can access disaster planning tools.

Summary Statement

Background information:

Hospitals play a central role in disasters by receiving an influx of casualties and coordinating medical efforts to manage resources

The majority of disaster protocols have been developed to address the occurrence of mass casualty events that occur outside of the hospital, where the hospital will be receiving large numbers of injured people in a short period of tim

Unfortunately plans have not been fully developed in the event that the hospital itself is severely damaged, either from natural disasters like earthquakes, or manmade events such as massive electrical failure or terrorist attacks. Of particular concern is the limited awareness of the obstetric units’ specialized needs in the world of disaster planning.

The obstetric unit is comprised of labor and delivery, antepartum, postpartum wards, and the newborn nursery. In each of these wards there exists a wide variety of patients ranging from preoperative to postoperative, low risk to high risk, medically stable to unstable, in all stages of labor. Nowhere else in the hospital is there such a variety of patient acuities so closely housed within the same unit.

In addition, obstetric units have the unique task of caring for not only one, but two (sometimes three) patients simultaneously. The job of assuring mothers and their newborn are evacuated together during a time of chaos is neither trivial nor simple. During Katrina, “125 critically ill newborn babies and 154 pregnant women were evacuated to Woman’s Hospital in Baton Rouge. Some of the fragile newborns arrived without their mothers. It was at least 10 days before some of the infants and mothers were reunited”. (Laksmi R.Washington Post 2006)

What is needed:

To accomplish a comprehensive obstetric disaster plan, there must be:
1) National adoption of a common triage and evacuation language including an effective patient tracking system to avoid maternal–neonatal separation
2) Stratification of maternity hospital levels of care
3) A collaborative network of obstetric hospitals, both regionally and nationally

#1 Adoption of a common Train Triage tool

Whether the need is to evacuate the facility or to prepare for increased surge capacity, a triage method is required to quickly and accurately assess patients.

Stanford Health Care has developed and trialed an obstetric triage system called OB TRAIN (Obstetric Triage by Resource Allocation for INpatient) using the framework of a similar tool created by the NICU. When tailoring a triage system for obstetric patients, we considered four crucial parameters, allowing suitable transportation of the patient to the most appropriate facility. This is included in the toolkit for labor and delivery and AP patients.

Beyond evacuation, other considerations during a disaster:

Other considerations during a disaster should include a detailed plan for “Shelter in place”, which refers to the actions and equipment necessary to attend to those patients who cannot be safely moved and must be cared for in austere conditions. For example, patients those patients on labor and delivery who are going to deliver imminently or for other patients when immediate transport services are not available. Having pre-prepared kits for surgical and nonsurgical deliveries is essential for the care of patients outside our usual environment, whether this is elsewhere within the hospital or outside in the parking lot. A description of equipment that may be required to “Grab and GO” in these situations is included in this tool kit

“Surge capacity” refers to strategies that hospitals accepting patients from other damaged hospitals need to have, to be able to accept and adequately care for a higher census than is their norm. These forms are not yet available for the toolkit.

#2 Stratification for maternity hospitals level of care capacities

As of August 2019 ACOG has developed a Levels of Maternity Care Consensus
This includes 5 levels of maternity hospitals based on level of care provided by capabilities and providers available at each site

The 5 Levels

1. Accredited Birth Centers
2. Basic Care (Level l)
3. Specialty Care (Level ll)
4. Subspecialty Care (Level lll)
5. Regional Perinatal Health Care Centers (Level lV)

For more detailed information please see ACOG Obstetric Care Consensus: Levels of Maternal Care
Obstet Gyecol Aug2019:134 No 2

#3 Regionalization for collaborative networks

The use of preexisting collaborative networks during a disaster has been successful in other medical disciplines. After Hurricanes Katrina and Rita, the nation’s trauma centers (which have a collaborative network in place based on the trauma-level designation of 1, 2 or 3) were able to communicate regularly between centers about caseload, supply needs, and patient movement, amongst other things.

This type of collaborative network must also be created for obstetrical patients to allow efficient, safe and the correct transfer of patients between facilities. This undertaking should be done both on a local and statewide level to be able to clearly understand all the resources and location of resources in times of disasters.

What can YOU do?

1. Prioritize disaster planning for OB units
2. Create documents using the Stanford forms as a guide
3. Begin training of your staff
4. Promote regional collaborative networks for OB care in your area
5. Join a national collaborative for disaster planning for OB units to:
   1. Endorse a common OB triage tool to be used nationally
   2. Aid in the development of a maternal/newborn tracking system
   3. Adopt the use of Levels of maternity care based on the ACOG consensus statement Feb 2015
   4. Determine national standards for surge capacities and acceptable levels of care in a limited resource environment (shelter in place)
6. Give us your feedback to our toolkit so that we can refine and improve upon it