**4. Discussion**

With climate change, the incidence of wildfires that may lead to NICU evacuations are likely to increase. Therefore, it is important to be prepared and have e ffective plans in place to keep the most vulnerable population of babies, their caregivers, and medical sta ff as safe and healthy as possible [8].

Gaps in disaster preparedness exist and need to be identified, addressed and closed [9]. An example of a logistical gap is the inability to access temporary hospital privileges to "continue to take care of his or her patients in the receiving NICU" [10]. Congress and President George W. Bush saw gaps in disaster preparedness as a significant problem and established The National Commission on Children and Disasters in 2007 to try to close these gaps through a "cohesive national strategy ... to protect children during disasters" [9].

These disasters include hurricanes. In August of 2005, Hurricane Katrina necessitated evacuation of NICUs as well. Dr. Barkemeyer explained what happened to the babies, hospital, city, trainees, and family while he was "on duty in the NICU of a flooded downtown New Orleans hospital" [11]. As a result of Katrina, babies were triaged and transported to other hospitals and a preterm baby girl was born four days after Katrina's landfall and cared for using equipment on a portable generator [11]. Similar to our interviews focused on wildfires, communication methods following Hurricane Katrina was an issue [11].

Clearly, disaster preparedness also applies to events that are not wildfires, which is further shown in published guidelines and resources with hopes of keeping the NICU population safe [8]. The Illinois Department of Public Health released the "Neonatal Intensive Care Unit (NICU) Evacuation Guidelines," planning in advance for transporting the NICU population and focuses on tornados, winter storms, flooding, and earthquakes (Illinois). The Illinois Guidelines sugges<sup>t</sup> identifying infants in multiple ways, such as standard ID bands and direct patient marking, as well as performing horizontal evacuation before vertical evacuation [12]. The New York City Pediatric Disaster Coalition and New York City Department of Health and Mental Hygiene made a broad template available online titled the *Neonatal Intensive Care Unit Surge and Evacuation Plan* in 2018 [4]. However, descriptions of evacuation plans are adapted in the moment, including "using a smartphone to take pictures of patient arm bands" to facilitate tracking [13].

Common themes of our study are shown below in Figure 4. This figure answers the leading questions we posed in the introduction: "What are some of the barriers in healthcare delivery for NICUs, especially if needing evacuation, that we may have learned from recent California wildfire experiences? What have healthcare team members and leaders learned about how to improve patient safety during a crisis like a wildfire that is encroaching on the hospital's door? What new ways have healthcare workers discovered and are enacting to e ffectively and e fficiently evacuate NICUs?"

**Figure 4.** Barriers and lessons learned from wildfire disaster experience in California NICUs.

A limitation of our study is that we did not have knowledge of actual transfer of babies to which hospitals as this was a qualitative study, and we did not have patient data. There may also have been recall bias given the amount of time that had elapsed since the disasters that the interviewees

discussed. Interviews were conducted from April 2019–May 2020. It is important to give health care members time to recover from crises and grieve, as these disasters can exert a heavy burden not only professionally but in personal lives. We aimed to have a balance in order to interview participants at a reasonable time in order to allow for an optimal recounting of the wildfire event while not causing undue stress.

Disaster resources for center internal evaluation of their own processes include the California Association of Neonatologists' Neonatal Disaster Preparedness Toolkit and Stanford's Disaster Planning Toolkit, both linked below.

