**3. Results**

Of the ten interviews, roles included NICU medical directors (*n* = 1), neonatologists (*n* = 2), nurse managers/directors (*n* = 2), neonatal clinical nurse specialists (*n* = 1), NICU nurses (*n* = 1), patient care managers (*n* = 1), and NICU department managers (*n* = 2). Overall, there were seven phone/remote conferencing software interviews and three online survey interviews. One participant was interviewed twice as their institution's NICU was evacuated twice in di fferent years.

While NICU level of care was not a focus of the questioning, the level of care came up in three of the interviewee's responses. One was Level II, one Level III, and one Level IV. Each interviewee was interviewed on their own. However, as stated in the Materials and Methods section, two people were interviewed from the same location for two of the locations in Northern California.

### *3.1. NICU Redundant Systems*

As seen in Figure 1, redundant systems were in place for power in 90%, medical gas in 90%, water in 70%, wall suction in 70%, and information technology in 70%.

**Figure 1.** Neonatal intensive care units (NICU) redundant systems.

### *3.2. Use of TRAIN*™ *Tool Nomenclature to Categorize Infants and Evacuation Preparedness*

Table 2 shows the prevalence of TRAIN™ tool nomenclature in NICUs, hospitals, and regions to categorize infants. It also depicts evacuation preparedness including having necessary supplies and an established evacuation plan.

**Table 2.** Use of TRAIN™ tool nomenclature to categorize infants and evacuation preparedness.


AAP: American Academy of Pediatrics; NICU: Neonatal Intensive Care Unit.

### *3.3. Please Describe Your Experience with [The Fire Incident] and the NICU Evacuation*

When participants were asked about their NICU Evacuation Experience, 50% of participants declared that smoke and air quality were an issue. Two participants alleviated the bad air quality by using air scrubbers to pull the particulates out of the air.

In terms of transport, 40% used ambulances, with three participants using bassinets in the back of ambulances to transport babies. Other babies were triaged by bus or private car transport. One participant spoke of evacuating babies that could be feasibly transported in a car seat to be transferred in that way, in order to increase the capacity of the transport system for sicker babies.

For supplies, two participants spoke of the use of backpacks; one participant was putting together a small backpack per baby bedside including formula, wipes, diapers, and feeding tubes.

Communication to alleviate confusion was lacking in some NICUs. In one instance, babies showed up at the receiving hospital without a call from the evacuating NICU asking for permission or providing warning. Internet and phone call issues did not help. One participant had to text or text someone else who had access to the other person to communicate.

Furthermore, delegation of responsibilities was problematic. One participant said if they could have changed one thing, it would be to have a clear command structure in the unit.

Documentation of baby's care was sometimes nonexistent by the receiving hospital. Compatibility of the electronic medical record (EMR) made a difference because it forced some medical professionals to have to chart on paper or wait for the nurse from the receiving hospital to chart for them. EMR incompatibility is an existing inefficiency even outside of a disaster context and is amplified even further when wildfire disaster strikes.

Forty percent of hospitals solved the problem of getting numerous babies out of the hospital at a time by using evacuation Med Sleds®. The Med Sled® Infant 6 can fit up to six babies in the pockets (Figure 2) and another can fit three babies on a sled (Figure 3) and quickly ge<sup>t</sup> them out the door into an ambulance. The sleds lock in place, removing worry about the babies falling out. One hospital even noted how they could place the ventilator in the sled for a baby that needed it. This is one of other potential solutions to navigating babies going down the stairs, if the elevators are not working, an important component to evacuation.

**Figure 2.** Med Sled® Infant 6 insert.

**Figure 3.** Med Sled® infant insert that can hold up to three infants.

Some participants took away getting as much supplies as they could if a disaster were to strike again and cause a NICU to evacuate; one hospital specified grabbing formula bottles and nipples. Two participants spoke of backpacks, with one putting together a daypack, a small backpack for each baby in case of emergency with formula, wipes, diapers, and feeding tubes and another revamping their backpacks.

Important to note in one hospital is that even though they tried ensuring people working in the NICU went through a streamlined vetting process, this did not happen for a number of people. This was an identified gap for future implementation work.

Infant identification was another concern by some of the hospitals. Ways to solve this problem that arose were making sure babies had ID bands on and stickers on their abdomens. A backup baby identification strategy may be important for local policies.

A theme from two informant interviews was limited storage space in the unit. One hospital did not keep the bassinets and incubators at hand, instead storing them in a couple of vacant patient rooms. Another hospital found it difficult to ge<sup>t</sup> equipment and supplies, including emergency food storage (formula), when the elevators are being used constantly and the hospital is chaotic.

Additionally, some participants explained the experience as traumatic or emotional with four participants relaying personal family issues including being evacuated or their house burning down as they were simultaneously helping NICU babies during the fire incident. Health care workers are resilient and selfless. Even though their own homes were burning down, they helped NICU babies stay safe and healthy.

### *3.4. Can You Describe Any Changes That Your NICU Implemented in Your Evacuation Procedures after the Experience with This Incident?*

In terms of changes the participant's NICUs implemented in their evacuation procedures after the experience with their corresponding fire incident, equipment was important to 50% of participants. Two participants cited bassinets for the perinatal patients, some with the ability to have oxygen attached to them. Another two participants spoke of aprons to carry babies, with one hospital realizing that they did not work well during their own evacuation.

### *3.5. Are There Other Aspects of Disaster Preparedness That You Think Are Gaps in Your NICU? (Source: NICU Disaster Preparedness Survey—Gap Analysis)*

When asked of gaps still existent in their NICU's disaster preparedness, two respondents said it was sta ffing. There were minimal or skeleton sta ff during the wildfire, and they could not rely on people on call because those workers could not always ge<sup>t</sup> to the hospital. Furthermore, a common theme was the evacuation plan. One hospital noted that they had a pretty solid evacuation plan while another said that they are working on an evacuation plan and need two plans: one for horizontal for issues in NICU only (fire, structural issues, etc.) and one for vertical (out of building).

Two participants were confident in their disaster preparedness as the previous incident went smoothly and there were no gaps in protocols or procedures. Among the other 80%, one respondent explained how you identify gaps as you go and adapt. Big gaps included not using all resources to the fullest extent, getting patients out, getting equipment, not using the TRAIN ™ tool for a live event or not having the TRAIN ™ tool work, and making sure people were participating in drills and training for these disasters even though it is "not that likely for evacuation to happen again." Another interesting insight was that the participant learned that they should have called the operation center instead of calling other potentially receiving NICUs themselves for better regional coordination and overlap prevention.

### *3.6. Can You Share Any Insights on How to Better Prepare for Future Disasters That Can Inform Neonatal Transport?*

The insights that participants had on how to better prepare for future disasters that can inform neonatal transport include 30% declaring practicing is important, for example by doing live drills every year. One participant has not started doing drills yet. Two participants specified coordinating with their county/region with the county or statewide drills and spoke of having necessary equipment. Safety was something that one participant brought up, citing the fact that their use of open cribs in the ambulance could have been safer, so the babies do not have the chance of sliding around, even though their open cribs did not slide around in their fire experience.

A major insight brought up by one respondent was about being flexible in terms of what you are doing even though it does not meet your job description. Being open minded and thinking outside the box about how to transport babies, even putting them in car seats for example, is very important. Staying calm was another important insight by a participant who said that their neonatologist and nurses were very calm and acted fast.

### *3.7. Is There Anything Else That You Would Like to Share?*

When asked for additional things to share, three spoke of community and a culture of team, with two specifying that even though the experience was personally traumatic with two of the team's main people: their neonatologist and manager's houses burning down, they still stepped up and showed up for their priorities. Sta ff did everything that needed to be done, some staying 48 h or longer. One participant is looking for the best models and is trying to teach that model to other areas, even implementing that model statewide as a possibility.
