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History of Health Care Facility Evacuations
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  1. History of Health Care Facility Evacuations OSHA Training Institute – Region IX University of California, San Diego (UCSD) - Extension OSHA Training Institute

  2. “If you wish to control the future, study the past.” -Confucius (551 B.C. to 479 B.C.) OSHA Training Institute

  3. Objectives • Examine Hazard Risks for hospitals which could result in need for evacuation,and special considerations needed for them • Recognize difference between Structural and Non-structural damage in a facility • Review the history of selected prominent hospital evacuations in the U.S. & Canada and reasons for evacuations • Review key lessons learned from these events OSHA Training Institute

  4. Risk Assessment for Hospitals-I • Relatively high rates of occupancy 24 hours/day, increasing probability of serious injuries and casualties in building collapse or other events • High incidence of special needs patients, immobile patients, and pts on life-support equipment • Complex floor plans, confusing to patients if lights are off at night. • Many chemical, biological and radiological products & explosive gases in hospitals OSHA Training Institute

  5. Risk Assessment for Hospitals-II • Fires and explosions from damaged mechanical and electrical equipment are hazards to life and property • Presence of infectious wastes and radioactive isotopes increase exposure risks over standard environments • Heavy equipment is hazardous if overturned OSHA Training Institute

  6. Risk Assessment for Hospitals-III • Desirable drugs, e.g. narcotics, may be sought after and stolen if normal security breaks down • Are often sites for helicopter ops OSHA Training Institute

  7. Evacuations • Move patients away from windows, to inner corridors • Move patients from one end of a floor to another (horizontal evacuation) • Move patients up or down one or more floors (vertical evacuation) • Move patients outside, out of danger • Direct inter-facility transports, or transports to patient evacuee shelters or Regional Evacuation Points OSHA Training Institute

  8. Main Building, Agnew State Hospital , Santa Clara County, CA. Built of unreinforced masonry, it collapsed in the San Francisco EQ, April 18, 1906. OSHA Training Institute

  9. Agnew State Hospital “…pinned many of the patients under fallen walls and debris.  The padded cells had to be to broken open and more dangerous patients were tied to trees out on the lawn in lieu of a safer place.” 170 out of 1,100 patients, 12 attendants and the 2nd senior physician were killed. Ref: http://www.sfgenealogy.com/santaclara/history /sc1906.htm OSHA Training Institute

  10. San Francisco Earthquake 1906 Mechanic’s Pavilion: Makeshift hospital for EQ victims and patients evacuated from St. Lukes & other hospitals OSHA Training Institute

  11. After the Earthquake came the fires…. OSHA Training Institute

  12. Mechanics Pavilion being evacuated as fire spreads towards it. OSHA Training Institute

  13. U.S. Hospital Evacuations 1971-1999 • Study of 275 instances reported in the media • Average of 21 per year in final decade • Most in a year was 33 in 1994, due to Northridge EQ Reference: Sternberg E, Lee GC, Huard D. Counting crises: U.S. hospital evacuations, 1971-99. Prehospital & Disaster Medicine 2004; 19:(2): 150-157. All were exceeded by the evacuations for Hurricanes Katrina and Rita, 2005 OSHA Training Institute

  14. Reasons for Hospital Evacuations, 1971-1999 • Internal fire - 23% • Internal Hazardous Materials (HAZMAT) events - 18% • Hurricanes - 14% • Human threat - 13% • Earthquake - 9% • External fire - 6% • Flood - 6% • Utility failure - 5% • External HAZMAT events - 4% Reference: Sternberg E, Lee GC, Huard D. Counting crises: U.S. hospital evacuations, 1971-99. Prehospital & Disaster Medicine 2004; 19:(2): 150-157. OSHA Training Institute

  15. Structural Affects load-bearing structures in the facility Examples: Foundations, beams, staircase supports Non-structural Affects non-load bearing structures Examples: windows, ceilings, light fixtures, electrical circuits, medical gases, water and sewer pipes Includes contents of facility: shelving, cabinets, refrigerators, lab supplies, monitors, computers, furniture Health care facility damage OSHA Training Institute

  16. Tasks to be Planned for Hospital Evacuations • Warning of an impending threat…how is plan activated? • Making the decision to evacuate • Determining destinations for evacuated patients • Safely moving out of damaged facility and to reception points • Avoiding moving patients to other facilities that will also need to evacuate • Tracking patients, attendees, and staff • Provisioning staff to care for evacuees and themselves • Transportation of patients and staff • Management of medical records, pharmaceuticals • Determining when it is safe to return, and managing it OSHA Training Institute

  17. Reported threats to hospital function: Power-related • Generator failure • Unanchored generator batteries, inadequately anchored generators • Damage to gas lines carrying fuel to emergency generators • Loss of water supply to cool emergency generators • Location of generators and switching equipment in flood-prone basements • Inadequate fuel supply for generators • Inadequate surge protection; inadequate generator capacity • Switching failure during kick-in of back-up power OSHA Training Institute

  18. Hospital evacuations may become necessary due to structural or non-structural damage, or threat of damage Causes of actual damage: Earthquake, flood, fire, hurricane, tornado, loss of power Examples of threatened damage: Hurricane warnings; Threat of dam or levee rupture; Encroaching wildfire; HAZMAT incident with evacuation area declared. OSHA Training Institute

  19. Mississauga General Hospital Evacuation - no damage to facility • 11/11/79: 24 of 106 railcars on Canadian Pacific Train 54 derailed in Mississauga, on western outskirts of Toronto. Rail cars carried 5 different toxic and flammable chemicals, include propane, butane, styrene and a leaking chlorine tanker next to the burning train • 250,000 residents evacuated from the area • Of 478 patients, 292 were discharged home, 186 transferred to 8 other hospitals. Two receiving hospitals later told also to evacuate. Henry S. Mississauga Hospital: largest evacuation in Canada’s history. CMA Jour 122:582-586, 1980. OSHA Training Institute

  20. When a wildfire threatens… OSHA Training Institute

  21. When Wildfires threatened a hospital… Children’s Hospital, San Diego, CA • “ In case of evacuation, Children's Hospital of San Diego, in Kearny Mesa, south of the flames, made tentative arrangements to transfer patients to the Navy Hospital ship USNS Mercy, docked in San Diego Bay, and to Scripps Mercy Hospital.” http://www.signonsandiego.com/news/fires/weekoffire/20031027-9999_7n27victims.html OSHA Training Institute

  22. Most Significant Hospital Events, U.S. 1971: Collapse of 4 buildings at the Veterans Administration Hospital, Sylmar,CA due to 6.6M San Fernando EQ. 49 deaths occurred. Unreinforced masonry walls crumbled. OSHA Training Institute

  23. VA Hospital, Sylmar, CA after 2/9/1971 EQ OSHA Training Institute

  24. VA Hospital Evacuation, Sylmar • 300 patients evacuated to various VA Hospitals within 2.5 hrs using school buses and commandeered vehicles • No first responder assistance for 90 minutes, hospital staff were “on their own.” Initial search & rescue done by 9 VA physicians & group of nurses and employees on scene. Unknown if PPE (hardhats, masks, gloves ) were available. • Last survivor was extricated from the rubble 58 hours after the EQ; digging continued for 5 days OSHA Training Institute

  25. VA Hospital Evacuation, Sylmar • Key lessons learned: • Set up Command Post. • Availability of “bullhorns” was critical to on-scene communications • Radios • Establish ability to communicate with first responders Ref. Heavey JF. “Firsthand account of earthquake destruction of VA Hospital at San Fernando, Feb 9, 1971: “All hell broke loose- my first earthquake.” OSHA Training Institute

  26. Most Significant Hospital Events, U.S. • LA County-Olive View Medical Center • New 6 story complex, dedicated on 1/9/71 • Life span of one month • “Totaled” on 2/9/71 • 3 deaths occurred • 2 on ventilators • 1 struck by falling debris when running outside • The Community Mental Heath Bldg at the Center totally pancaked down one story • No one in basement when 6.6 EQ occurred at 06:00 OSHA Training Institute

  27. Olive View Medical Center, 1971 Ambulance crushed by overhang Collapsed outdoor stair tower Olive View Medical Center 1st floor entrance to medical clinics area OSHA Training Institute

  28. Lessons Learned from San Fernando Earthquake - 1971 • Building codes were inadequate for hospitals to withstand Earthquakes. • Resulted in Uniform Building Code and 1972 Hospital Act and 1973 VA D • Design standard for hospitals; increased standards by 50% in 1976 OSHA Training Institute

  29. Impact of Hurricane Hugo on Surgical Services in a University Hospital, 1989 • Winds led to loss of emergency power and water • System failures occurred in air conditioning, vacuum suction, steam and ethylene oxide sterilization, plumbing, central paging, lighting and refrigeration Hurricane Hugo making landfall in Carolinas OSHA Training Institute

  30. Impact of Hurricane Hugo on Surgical Services in a University Hospital, 1989 • Surgical support services lost: • Blood bank: No platelet packs for 2 days • Radiology: CT/MRI Scanners damaged; flooding ruined patient files • ICU: No monitors; hand ventilation of ventilator patients • OR: Loss of temperature and humidity control (steam, H2O, suction); elective surgery halted for 11 days. OSHA Training Institute

  31. Impact of Hurricane Hugo on Surgical Services in a University Hospital, 1989 • Recommendations for planning for hurricanes • Augmented ancillary services staffing • Evacuation of as many critical patients as possible before the storm. Norcross ED, et al. Am Surg 59(1):28-33, 1993 OSHA Training Institute

  32. Hospital Disaster Operations during the 1989 Loma Prieta Earthquake • Magnitude 7.1 EQ struck northern CA on 10/17/89 at 1704 hrs • Epicenter 75 miles south of SF near Loma Prieta Peak in the Santa Cruz Mts. • 42 people killed in collapse of the Cypress Structure ( elevated freeway in Oakland.) • Major impact on health care services OSHA Training Institute

  33. Hospital Disaster Operations during the 1989 Loma Prieta EQ • 43% of hospitals had inadequate back-up power configurations • 5 hospitals sustained total back-up generator failure • 20 hospitals performed partial evacuations; none required complete evacuations OSHA Training Institute

  34. Hospital Evacuations during the 1989 Loma Prieta EQ • Evacuees were: • Ambulatory psychiatric or alcohol-rehab patients in 3 hospitals • From clinic and medical office buildings at 4 hospitals • Horizontal patient evacuations (moved to another area on same floor) at 3 hospitals due to broken windows • Vertical evacuations of non-ambulatory, Med-Surg, OB, Nursery and Pediatric patients at 3 hospitals • Non-ambulatory patients were hand-carried downstairs on sheets or in wheelchairs. OSHA Training Institute

  35. EQ-related equipment dysfunction during the 1989 Loma Prieta EQ in 51 hospitals • Elevators: • Lack of power in 20 (39%) • Damage by shaking in 6 (11.8%) • Roof fans knocked off bolts in 6 (11.8%) • Water pipes damaged by shaking in 5 (9.8%) • Cabinet contents spilled by shaking in 5 (9.8%) • Potential HAZMAT spill in 4 (7.8%) • Equipment falling (monitors, O2, TV sets) in 3 (5.9%) OSHA Training Institute

  36. Loma Prieta EQ: Staff anxiety and fear • Hospital and health care institution staff in an EQ are also victims of the EQ • Fear for family and homes pose significant problems • One hospital excused one person per floor to check the families of the staff for that floor • Firefighters brought the children of hospital employees into the hospital • Child care on site for day(s) after the EQ is key (due to school closures) in relieving staff anxiety OSHA Training Institute

  37. Northridge, CA Earthquake -1994 • 6.7 M EQ at 04:31 hrs on Jan. 17, 1994 • Sepulveda VA Hospital, all power and emergency generators failed; broken pipes flooded many buildings, staff scrambled to manually ventilate pts on respirators, often crawling thru debris. Supply doors jammed shut; Suction machines were under rubble. • Decision was made to evacuate facility, ambulatory pts first, then wheelchair pts, using flashlights to see. 331 pts. evacuated by 06:00 hrs. OSHA Training Institute

  38. Northridge, CA EQ - 1994 • Six hospitals evacuated patients immediately • 4 evacuated all inpatients • 5 evacuated sickest patients first. • 6th evacuated healthiest first, fearing imminent collapse, “…the greatest good for greatest number.” 334 pts evacuated to open areas outdoors in 2 hours. • All used improvised transport devices (backboards, blankets, mattresses) OSHA Training Institute

  39. Damage, 3rd floor, water break from roof tank Northridge EQ 6.7 M Granada Hills Community Hospital Pts. On top 2 floors evacuated to 1st floor, ED stays open OSHA Training Institute

  40. Medical office building, of recent construction, reinforced concrete, fails during Northridge EQ, Jan 17, 1994. OSHA Training Institute

  41. Sept. 2, 1993 “ a faulty respirator exploded in the ICU, leading to 3 deaths and the evacuation of 120 others….” OSHA Training Institute

  42. Tropical Storm Allison, Houston, TX June 2001 • Texas Medical Center: • 40 institutions • 54,000 employees in downtown Houston • 12-15 inches of rain in < 9 hours. OSHA Training Institute

  43. Tropical Storm Allison, Houston, TX June 2001 • Shortly after midnight on 6/9/01,10 million gal. of water poured into basement and the ground floor of the UTX Medical School and Memorial Hermann Hospital • Had to reassure, treat and transfer 540 patients to other hospitals, up to 200 miles away. OSHA Training Institute

  44. Tropical Storm Allison, Houston, TX June 2001 • Issues at Memorial Hermann Hospital • Staff worked for 48 or more hours straight, without sleep • ICU pts on ventilators required ventilation by hand with Ambu- bags for hours to days • Evacuations of 540 pts was on backboards down unlit, hot, humid stairwells by flashlight • Creation of a “temporary Emergency room” for patients and staff who might get ill during their transfer OSHA Training Institute

  45. Tropical Storm Allison, Houston, TX – June 2001 • Issues at Memorial Hermann Hospital • Paper trail for each patient had to be created, to track where they went. • No 911 or EMS system for back up, due to flooding, power issues • New helicopter LZ had to be created for Medevac by USCG, National Guard and Life Flight rotorcraft, with attendant safety issues for people not used to working around helicopters OSHA Training Institute

  46. How are such events “Planned for?” • Use of HICS, the “Hospital Incident Command System” • Creation of an “Internal Emergency Action Plan,” a Disaster Plan for Internal Events • Exercise of the plan regularly, to avoid the “Paper Plan Syndrome” • Involvement of all levels of facility administration and operations people in exercise planning and response • Improve the plan through Exercise Critiques, “Hot Washes,” After Action Reports, Lessons Learned OSHA Training Institute

  47. Super Typhoon Pongsona, Guam – December 2002 • Located 3,700 miles SW of Hawaii (other side of Int’l Dateline) • Struck Guam and Rota on Dec 8-9, 02 • 180 mph winds, 15-25 foot wave heights • Fuel tank farm fire decreased availability of fuel for generators OSHA Training Institute

  48. Super Typhoon Pongsona, Guam – December 2002 • Guam Memorial Hospital, the only civilian hospital on the island, is a former navy hospital. • GMH emergency dept flooded, windows broke in the ICU caused significant wind damage in halls, ceilings • No injuries, due to evacuating staff and patients to “inside rooms.” Critical patients were evacuated to the ICU at Naval Medical Center in Guam OSHA Training Institute

  49. Super Typhoon Pongsona, Guam – December 2002 • US Air Force Field Hospital, flown in from Japan, was set up outside hospital • DMATs deployed to provide care, substituting for MD officers, pharmacies, “unload ERs.” OSHA Training Institute

  50. Hurricane Katrina-Aug. 2005 • Three Landfalls: 8/25/05 near Miami, FL (Cat 1) & 8/29/05 Near New Orleans delta area (Category 4) at 06:10 hrs; and near 11:00 hrs-Noon near Gulfport/Biloxi, MS • >80% of the City of New Orleans flooded from levee breaks • Official death toll as of 3/7/06 = 1,422. (includes >1,000 in LA) • Displaced >1,000,000 people • Area covered by disaster declaration = 90,000 sq.mi., almost equals area of UK. OSHA Training Institute