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Lessons from Hurricane Katrina: A Risk Based Approach to Hospital Evacuation. Chris Johnson Boyd Orr: Julia Appleby, Peter Cooper, Andrew Foss, Stephen Hailey, Benjamin Jenks, Western Infirmary: Fouria Ashraf, Graham McKinlay, Chris McAdam, Jody Johnson, Martin Wilson

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Lessons from Hurricane Katrina: A Risk Based Approach to Hospital Evacuation

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Lessons from Hurricane Katrina:A Risk Based Approach to Hospital Evacuation

Chris Johnson

Boyd Orr: Julia Appleby, Peter Cooper, Andrew Foss, Stephen Hailey, Benjamin Jenks,

Western Infirmary: Fouria Ashraf, Graham McKinlay, Chris McAdam, Jody Johnson, Martin Wilson

University of Glasgow, Scotland.

http://www.dcs.gla.ac.uk/~johnson


Strathclyde Fire Brigade.

BFRL, US NIST.


Hurricane Katrina

  • Several precursors (Tropical Storm Alison).

  • East Jefferson General Hospital:

    • ad hoc evacuations of elderly patients;

    • waded from emergency department ramp;

    • elderly care home that was being inundated.

  • Clinicians and support staff at New Orleans’ University Hospital:

    • carry patients down 4 flights of stairs;

    • take them to an improvised ICU when generators flooded.

  • Chairman of medicine at Tulane University Hospital:

    • forced to use a colleague’s canoe;

    • coordinate with New Orleans’ University Hospital and Charity Hospital;

    • phone lines failed.


Hurricane Katrina

  • Investigations into multiple fatalities during evacuation of Memorial Medical Center.

  • Patients on 7th floor carried through hospital.

  • Many spent considerable time waiting for boat.

  • Hospital administrator said deaths due to ‘systems failure’.

  • Criticized lack of guidance on preparation for mass evacuations.


Legislation

  • International Building Code in 40+ US states - show “construction, size & character of means of egress” and numbers in each space.

  • OSHA - employers ‘ensure routes leading to exits are accessible and free from materials or items that would impede evacuation’.

  • UK Fire Precautions (Workplace) Regulations meet EC Directives 89/391 and 89/654 - employers responsible for outcome of adverse event.

  • Risk-based approach - must demonstrate any precautions are appropriate to the likelihood and consequences of any hazard.

  • Evacuation measures could be use to demonstrate mitigation of the potential consequences of an adverse event.


  • 2001 Department of Health

  • “NHS Trusts must have an effective fire safety management system”

  • They must “ensure emergency evacuation procedures for all areas and undertake fire risk assessments”

  • Specialist Fire Officers focus on “fire safety audit and fire risk assessments and assisting with reports to management”


But How Do We Do It?

  • There are few specialist techniques.

  • Risk assessment for fire:

    • Only consider evacuation as a mitigating factor?

    • Can we reason about risk of evacuation hazards?

    • Legislation is ambiguous in this area…

  • Slight change in emphasis, focus on evacuation

    • 1. consider risk of hazards that require evacuation;

    • 2. consider risks of conducting successful evacuation.


Plan of Munich Lowenbraukeller (April, 1973)


  • Evacuation of Summerland Bar, Isle of Man:

  • 51% use the entrance (37 guests, 1 staff member);

  • - 49% use emergency exit (23 guests, 14 staff).


Woolworths fire in Manchester:

- 9 out of the 10 fatalities in canteen;

- didnt leave before finishing or paying for meal?


Hospital Fires

  • Edleman et al (1980) study care home fire.

  • 95% (85) led down one staircase, 3 others available.

  • Normal route for staff and patients between floors.

  • Other 3 were evacuation routes with entry alarms.

  • Reluctance to use them even when fire justified it.

  • Evacuation longer than designer & Fire Officers think.


Brooklyn Fire

  • Fire breaks oxygen hoses treating patient.

  • Wall outlets now allow free-flow oxygen.

  • Smoke into hall and patient floor.

  • Must evacuate many bed-bound patients.

  • Nurses delay to close area valves:

    • residual pressure before treatment stops;

    • Could use back-up bottled oxygen;

    • But bottles create another fire hazard.


Virginia Fire

  • 5 die, well designed building, well trained staff.

  • Less night staff, day staff very busy.

  • Alarm to fire dept out of service.

  • Main aim is patient care not fire safety?

  • Oxygen enriched environment.

  • Doors wedged open in many wards.

  • Smoke in ceiling space, fatality distribution.

  • No sprinkler system also a risk in itself.


Operating Room Fires

  • Joint Commission on Accreditation of Healthcare Organizations

    • 100-200 operating room fires each year in US.

  • Oxygen-enriched environment.

  • Ignition sources eg lasers and cautery units.

  • Evacuation risks for patients - ICU sedation.

  • Train for extinguishers in sterile environments.


Tropical Storm Alison

  • 3 hospitals close to new patients.

  • 2 evacuated most critical patients.

  • 1 hospital completely evacuated.

  • Shutting down 2000+ beds.

  • 500+ ICU beds for the City of Houston.

  • Alison also closed 1 of Houston’s 2 level I trauma hospitals - serves 4 million people.


Lack of Incident Reporting

  • But no national or Federal registers for these events.

  • Scots NHS reports fires involving death or serious injury to HSE.

    • Fires involving death, serious injury or serious damage to Dept of Health.

    • No information on less serious events or successful evacuations;

    • 1994-2001 only 6 reports. 5 involved smoking, 1 ‘willful’ fire raising.

  • Even for serious events, litigation prevents lessons from being learned.

  • Fire Officers rely on ‘war stories’, word of mouth in meetings and exercises.

  • Contrast with legal reporting requirements for device failure in healthcare.


US Hospital Fire Drills

  • 3 mock fire drills during a 6-week period.

  • Electrosurgical pencil ignites drape.

    • Staff remove cover from patient,

    • throw onto floor, use extinguisher.

    • Organisers then say fire spread.

  • Simulate move of intubated patients

    • OR bed with a bag-valve mask.

    • Pack wounds with sterile sponges;

    • e.g. don’t move anaesthesia machine.

  • Gridlock, rooms evacuate at same time.


US Hospital Fire Drills

  • Debrief sessions especially if problems.

    • poor emergency response checklist;

    • delays in backup if patient and anaesthetist ‘injured’ in exercise.

  • Anaesthetist evacuate by OR back door:

    • steep incline above a busy road;

    • Hospital posts signs on doors.

  • ‘Systemic’ problems:

    • hospital paging coordinates response;

    • announcements could not be heard;

    • staff leave posts to check;

    • No plans if it were damaged;

    • messenger post opened & buy radios.


Case Study Hospital


Horizontal Evacuation

  • Does movement create greater risks than hazard?

  • Check location of fire, secure refuge & exit route:

    • Refuges within 12 meters of each patient’s room;

    • 70 secs to move patient to place of safety;

    • 30 secs more for staff to return to patient’s room.

  • Patients in immediate danger moved first.

    • Non-ambulatory before mobile patient & visitors;

    • Wheelchair patients grouped together ;

    • Staff lead mobile patients in a single journey.

  • Patients must not impede emergency personnel.

    • 3 people, 5 mins to disconnect/reconnect units;

    • 15 mins, conscious patient bed to wheelchair.


But…

  • Wisconsin urges staff not to use ‘horizontal’ evacuation:

    • evacuations should move all patients outside the building;

    • ‘required, regardless of building construction’;

    • ‘may not use defend in place methodologies’ drills too;

    • use of patients in drills is optional.

  • Department of Health in Scotland:

    • “less annual fire training if risk assessment carried out”;

    • “fire safety training appropriate to duties of the staff”;

    • “at least annually for staff involved in patient evacuation”.


Limitations of Drills

  • Sustained Costs.

  • Limited Accuracy.

  • Short ‘Shelf Life’.

  • Lack of Design Focus.

  • Danger.

  • Poor Reliability.


Crowd Density and Velocity

Thompson and Marchant (1995)


  • Simulation results:

  • over 20 runs;

  • Blocking exits;

  • Lower figures are SDs.


  • Faster evacuation under model conditions:

  • North exit closed and a long way to main exit;

  • BUT only one bottleneck/door to main exit.


Modelling Nurse Behaviour

  • Coding of nursing staff behavior based on concurrent threads.

    • program creates an independent process for each individual.

    • Communication through a form of message passing;

  • Reactive route finding for each nurse using A* algorithm:

    • Simulated nurse ranks each possible moves from their current location;

    • Only go on to consider the next set of available moves from the top ranked adjacent position;

    • planned route gradually grows by always picking best next step for further consideration;

    • if potential route blocked then consider second route in the list of preferences.

  • Algorithm depends on appropriate heuristic:

    • Euclidian distance or detailed information about hospital layout;

  • Recall:

    • nurses modeled as independent threads and

    • each uses own independent navigation strategy;

    • contention will occur if 2 nurses move 2 beds along narrow corridor.

  • Specialist negotiation algorithms needed to resolve bottleneck.


Patient Preparation and Evacuation


Simplifying Assumptions

  • Timings for equipment on one floor of a particular hospital.

  • No obstacles – is this likely in a busy ward?

  • Bed movement did not require complex rotations for sharp corners.

  • Beds movements depends on model and maintenance provided:

    • Beds approx. 1 meter (38 inches) by 2.2 metres (86 inches).

    • Wheelchairs 0.75 metres (30 inches) by 0.75 metres (30 inches).

  • However, there were several different models.

    • Some wheelchairs upholstered similar to a moveable armchair.

    • others were based around more conventional metal frames.

  • No smoke, no cumulative fatigue effects etc.


Input and Output to G-HES


Summary


Further Work

  • RPDN on evacuation response.

  • Emergency ingress not just egress.


Questions?

Thanks are due to Julia Appleby, Peter Cooper, Andrew Foss, Stephen Hailey, Benjamin Jenks,

Fouria Ashraf, Graham McKinlay, Chris McAdam, Jody Johnson, Martin Wilson...


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