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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

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.


hurricane katrina
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 katrina6
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.
  • 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
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.

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
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
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
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
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
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
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
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 drills25
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.
horizontal evacuation
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.
  • 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
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
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.
simplifying assumptions
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.
further work
Further Work
  • RPDN on evacuation response.
  • Emergency ingress not just egress.


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

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