Two FEMA personnel sitting at a desk with two men, a woman, and two children
FEMA Personnel Helping Hurricane Ian Survivors Register for Assistance in Florida, October 19, 2022 (Source: FEMA).

Beyond Patient Care: Family Reunification Planning for Hospitals

Following a disaster, friends and family will try to reconnect with those affected by the incident as soon as possible. This means that hospitals and other healthcare facilities must have plans and procedures in place for mass casualty incident response beyond patient care. Surge capabilities for significant additional activities include patient registration and tracking, family reunification, and coordination with external entities. If nonpatient-care activities are not planned, organized, equipped, trained, and exercised in advance, the impact could overwhelm any healthcare facility and compromise its ability to deliver lifesaving care:

Disasters and mass casualty incidents can strike at any time, separating families and friends from their loved ones or displacing them for long periods of time. Some patients will not survive, and family notification and support must be provided. Patient tracking and family reunification and support services are key aspects of disaster response and recovery, but also some of the most challenging. Hospital-based family support actions and centers must also integrate activities and referrals with community-based resources and Family Assistance Centers. (ASPR/TRACIE/HHS, 2023)

The Community’s Need for Supporting Reunification Efforts in Disasters

In the U.S., emergency management categorizes family reunification under Emergency Support Function #6 (ESF-6) Mass Care during disasters because evacuations often involve sheltering – and shelters collect registration information from evacuees. Today’s disaster shelter could also become tomorrow’s community resource center. For example, when communications systems are down, residents gravitate to disaster operational sites to connect to the outside world. The same applies to hospitals, which may be a closer location and will generally have power and communications capabilities. Hospitals may also have casualties from the incident – and their friends and families will travel there to reunify. These reunification processes at different sites cannot operate in silos. They must be collaborative, coordinated, and communicative with each other. Hospitals should be a support partner to the Incident Command (through ESF-6 or ESF-8 – Public Health) for reunification, in the same way they are for mass casualty care.

As a complex mission under ESF-6, the safe and secure process of reuniting friends and family with those who were missing, injured, or even deceased should be a priority for any governmental or nongovernmental organization. Significant life safety and incident stabilization concerns exist if family reunification is not performed or is done incorrectly. Even without physical injuries, patients and their friends and families will enter hospitals with trauma and other concerns that the receiving facilities must triage. In most cases, hospitals will collaborate with external partners before making a reunification decision.

There will be requests for reunification support in languages other than English. There may be requests from law enforcement agencies for criminal investigations and missing persons. Requests may come from the American Red Cross and other nongovernmental organizations, such as the National Center for Missing and Exploited Children. Other nations may send requests via governmental public health organizations through embassies and consulates. All of these requests for reunification support are covered under the Health Insurance Portability and Accountability Act’s distribution of patient health information for the direct benefit of the patients. As such, hospitals should plan to:

  • Be part of the existing governmental organization’s emergency management plan for family reunification,
  • Originate or activate their own family reunification plan, or
  • Both (cascading or collectively).

Examples include:

  • An incident of scale occurred at a site that did not have suitable facilities for family reunification, so several injured patients were transported to the hospital.
  • A family reunification process began elsewhere. However, as the number of hospital transports increased, a collaborative decision moved the family reunification process to the hospital.
  • Government officials requested that the hospital establish a family reunification process in anticipation of a mass casualty incident at a planned event (i.e., consequence management planning for Special Event Assessment Rating events).
  • An incident occurred on hospital property, and it remained safe to establish family reunification on-site.

A hospital’s family reunification protocol should be collaborative with other organizations – especially those that have custodial relationships with their constituents and will have their own protocols in place for family reunification when incidents occur at their own sites. Examples include: a K-12 school (a bus crash on an interstate highway generating a mass casualty incident); an adult day care center (transport vehicle’s driver shot at, carrying people to a center); or a nursing home (evacuated due to fire). However, there also may be situations where communications to the public should not be made for reunification protocols, for patient safety reasons – for example, domestic violence shelters, developmentally disabled group homes, or human trafficking concerns (i.e., incident evacuating a migrant shelter, generating patients to the hospital). Again, the coordination with emergency management officials in the jurisdiction – through their Emergency Operations Center – will be able to resolve these concerns in a timely manner.

Recommendations and Action Items

To ensure effective reunification plans are in place, the author strongly recommends that hospitals participate in governmental and nongovernmental organizations’ family reunification training and exercises. In addition, hospitals should invite governmental and nongovernmental organizations to participate in their own family reunification training and exercises – especially partners with key response actions in the hospital’s mass casualty and family reunification plans. Small and rural hospitals will benefit from the collaboration and coordination, which is needed in both sets of plans, which may require extra sites, staffing, and other resources beyond the capacity of the hospital itself. The following best practices emerged from research of family reunification planning models:

  • Use a multi-site construct, one that houses a Friends and Family Reception Center, a Pediatric Safe Area, a formal Family Assistance Center (modeled after the design from the National Transportation Safety Board), and private or semi-private meeting room areas for direct interactions with families.
  • A whole-of-community approach (both within the hospital and with its external partners) works best. Speed-to-scale is important, but so is a patient’s safety and privacy. Nongovernmental organizations may be able to help with staffing for disaster health services, disaster mental health, and disaster spiritual care to supplement hospital staffing.
  • The reunification process works best in person. Trying to reunify over the telephone or through the internet is fraught with problems and presents large windows for liability concerns and patient or staff risk.
  • Triaging friends and family requires more space or rooms at a site or facility but will help preserve patient safety and privacy, provide consistent service and support, and move people efficiently through the family reunification process.
  • Make decisions about media access early and communicate them broadly and quickly. Generally, media access is limited to specific sites. However, in today’s hyperlocal news and social media environments, anyone with a smartphone can be live on national news from anywhere with a signal. The hospital’s public information officers (PIOs) must coordinate continuously with other PIOs.

Plan for a long duration of mission activity. Anticipate that the family reunification sites could be open for days or weeks. Decisions about relocation or demobilization must include consideration for the hospital’s continuity of operations.

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Figure 1. Family Reunification Outcomes (Source: Barton Dunant, used with permission).

Partial outcomes (e.g., some patients were sent to one hospital, some to others, discrepancies over custodial rights, etc.) may be circular and continue in the family reunification process. If the incident is still surging, friends and family may repeat this process to reunite with other patients arriving at different times. In addition, the family reunification process may occur in multiple existing areas of the hospital or specifically designated new ones (the Friends and Family Reception Center, the Family Assistance Center, and the Pediatric Safe Area) and has this type of flow:

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Figure 2. Friends, Family, and Patient Flow Model (Source: Barton Dunant, used with permission).

In this flowchart, as friends and family move left to right on the top row, beginning with the Friends and Family Reception Center, admitted patients move from the middle to the right after any necessary decontamination, triage, and treatment. Discharged (i.e., treated and “released”) unaccompanied minors must go to a pediatric safe area. And discharged adults can go to the Family Assistance Center for reunification. It is important to note that many scenarios exist where a family cannot leave the hospital on the same day they are reunited. For these and other circumstances, the length of time that visitors remain at the hospital in the family reunification process varies and requires support from other mass care elements (feeding, sheltering, and distribution of emergency supplies such as comfort kits). To accommodate these variances, each staff role will need a backup, shift replacement support, etc., which may require additional temporary staff.

Incorporating exercises, real-world examples from this hospital system and its other sites, and new scenarios and injects that were not part of the original design – including consequence management scenarios – can improve a hospital’s family reunification plan. For example, exercises could include how the hospital’s family reunification process would be implemented differently if:

  • The incident involved VIPs interwoven with other people, including private security details,
  • The incident involved government officials, their staff, and family members with public law enforcement protection,
  • One or more individuals were a Megan’s Law offender (i.e., registered as a sexually violent person),
  • COVID-19 or other public health emergency protocols were in place,
  • The incident involved chemical, biological, radiological, nuclear, or high-yield explosives that require decontamination protocols,
  • Severe weather conditions generated a shelter-in-place order, or
  • The hospital was a direct target of an attack that generated the need for reunification.

Hospitals have the opportunity and responsibility to be a supportive partner to a community’s family reunification needs. Collaborating with governmental and nongovernmental partners can benefit everyone by ensuring proper planning, organization, equipment, systems, training, and exercising.

Michael Prasad
Michael Prasad

Michael Prasad is a Certified Emergency Manager®, a senior research analyst at Barton Dunant – Emergency Management Training and Consulting (www.bartondunant.com), and the executive director of the Center for Emergency Management Intelligence Research (www.cemir.org). Mr. Prasad has held emergency management director-level positions at the State of New Jersey and the American Red Cross, serving in leadership positions on more than 25 disaster response operations, including Superstorm Sandy’s response and recovery work. He researches and writes professionally on emergency management policies and procedures from a pracademic perspective. His first book, “Emergency Management Threats and Hazards: Water,” is scheduled for publication by Taylor & Francis/CRC Press in September 2024 – and will now have updates based on this water-related incident. He holds a Bachelor of Business Administration degree from Ohio University and a Master of Arts degree in emergency and disaster management from American Public University. Views expressed do not necessarily represent the official position of any of these organizations.

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