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History of Health Care Facility Evacuations

OSHA Training Institute – Region IXUniversity of California, San Diego (UCSD) - Extension

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“If you wish to control the future, study the past.”

-Confucius (551 B.C. to 479 B.C.)

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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

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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

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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

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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

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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

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Main Building, Agnew State Hospital , Santa Clara County, CA.

Built of unreinforced masonry, it collapsed in the San Francisco EQ, April 18, 1906.

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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

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Mechanic’s Pavilion: Makeshift hospital for EQ victims and patients evacuated from St. Lukes & other hospitals

San Francisco Earthquake

1906

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After the Earthquake came the fires….

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Mechanics Pavilion being evacuated as fire spreads towards it.

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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

U.S. Hospital Evacuations 1971-1999

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

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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%

Reasons for Hospital Evacuations, 1971-1999

Reference: Sternberg E, Lee GC, Huard D. Counting crises: U.S. hospital evacuations, 1971-99. Prehospital & Disaster Medicine 2004; 19:(2): 150-157.

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Health care facility damage 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

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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

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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

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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.

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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.

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When a wildfire threatens…

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When Wildfires threatened a hospital…

“ 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

Children’s Hospital, San Diego, CA

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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.

Most Significant Hospital Events, U.S.

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VA Hospital, Sylmar, CA after 2/9/1971 EQ

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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

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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.”

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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

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Olive View Medical Center, 1971

Collapsed outdoor stair towerOlive View Medical Center

1st floor entrance to medical clinics area

Ambulance crushed by overhang

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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

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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

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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.

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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

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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

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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

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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.

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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%)

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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

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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.

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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)

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Northridge EQ 6.7 M Granada Hills Community Hospital

Damage, 3rd floor, water break from roof tank

Pts. On top 2 floors evacuated to 1st floor, ED stays open

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

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Sept. 2, 1993

“ a faulty respirator exploded in the ICU, leading to 3 deaths and the evacuation of 120 others….”

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Tropical Storm Allison, Houston, TX June 2001

Texas Medical Texas Medical Center: Center: 40 institutions40 institutions 54,000 employees 54,000 employees

in downtown in downtown HoustonHouston

12-15 inches of 12-15 inches of rain in < 9 hours.rain in < 9 hours.

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Tropical Storm Allison, Houston, TX June 2001

Shortly after midnight on 6/9/01,10 million gal. of Shortly after midnight on 6/9/01,10 million gal. of water poured into basement and the ground floor of water poured into basement and the ground floor of the UTX Medical School and Memorial Hermann the UTX Medical School and Memorial Hermann HospitalHospital

Had to reassure, treat and transfer 540 patients to Had to reassure, treat and transfer 540 patients to other hospitals, up to 200 miles away.other hospitals, up to 200 miles away.

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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

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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

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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

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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

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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

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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.”

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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.

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Hurricane Katrina – Aug. 28, 2005

97 Hospitals were impacted by Hurricane Katrina (Southern LA, AL & MS) 70 Medical Surgical Hospitals 11 Psychiatric Hospitals 1 Children's Psychiatric Hospital 4 Rehabilitation Hospitals 2 Other Specialty Treatment Hospitals 1 Children's Medical Surgical Hospital 1 Obstetric and Gynecology 2 Acute Long Term Care Hospital 1 Children's Acute Long Term Care Hospital

http://planning2.com/NewOrleansHospitalsKatrina.htm

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Hurricane Katrina – Aug. 28, 2005

30 hospitals evacuated, accounting for 22,200 hospital workers and 5,048 beds

Accounted for >145,000 inpatient admissions in 2004

http://planning2.com/NewOrleansHospitalsKatrina.htm

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VA Gulf Coast Veterans GULFPORT MS 39531 Closed, Not Accepting PatientsChalmette Medical Center CHALMETTE LA 70043 EvacuatedChildren's Hospital NEW ORLEANS LA 70118 EvacuatedCrosby Memorial Hospital PICAYUNE MS 39466 EvacuatedHealthsouth Specialty Hosp NEW ORLEANS LA 70127 EvacuatedHealthwest Rehab Hospital GRETNA LA 70056 EvacuatedKenner Regional Medical CenterKENNER LA 70065 EvacuatedKindred Hospital - New Orleans NEW ORLEANS LA 70115 EvacuatedLifeCare Hospital, Chalmette CHALMETTE LA 70043 EvacuatedLifeCare Hospital, Baptist NEW ORLEANS LA 70115 EvacuatedLifeCare Hospital, Kenner KENNER LA 70065 EvacuatedLindy Boggs Medical Center NEW ORLEANS LA 70119 EvacuatedMeadowcrest Hospital GRETNA LA 70056 EvacuatedMemorial Medical Center NEW ORLEANS LA 70115 EvacuatedMethodist Hospital NEW ORLEANS LA 70127 EvacuatedNew Orleans Adolescent NEW ORLEANS LA 70118 EvacuatedRiver Oaks Hospital NEW ORLEANS LA 70123 EvacuatedSt Charles General Hospital NEW ORLEANS LA 70115 EvacuatedTouro Infirmary NEW ORLEANS LA 70115 EvacuatedTulane University Hospital NEW ORLEANS LA 70112 EvacuatedVA Medical Center NEW ORLEANS LA 70112 EvacuatedMed Center of LA at N.O. NEW ORLEANS LA 70112 EvacuatedRiver Oaks Child & Adolescent NEW ORLEANS LA 70123 EvacuatedLakeside Hospital NEW ORLEANS LA 70117 Evacuated

Partial list of evacuated hospitals following Katrina 9/5/05

Courtesy of Planning 2.0 LLC, Franklin, TN

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Kiholo Bay EQ

Kona Community Hospital: 94 bed acute and long-term community hospital in Kealakekua, HI

Beds: 49 acute, 11 psychiatric, 34 long-term beds

Sunday, 10/14/06: Two EQs (6.6 & 5.8 magnitude) caused moderate non-structural damage to facility, loosened ceiling tiles, equipment knocked to the floor; 10 acute-care pts evacuated to Hilo. ED remained open.

30 nursing-care-level pts evacuated temporarily to nearby Sheraton Conference Center, HI-1 DMAT activated, deployed to manage evacuees

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Kiholo Bay EQ

Ceiling tiles downed after EQ

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Kiholo Bay EQ 2006 Other evacuations and

Hospital impacts: Kohala Community Hospital,

Kapaau (North Kohala), HI 28 bed facility evacuated long-term care

residents to the cafeteria to allow clean-up of non-structural damage

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Kiholo Bay EQ 2006

Other evacuations and Hospital impacts:Hale Ho’ola Hamakua Hospital, Honukaa, HI

Worst damage from broken water pipes 49 patients evacuated to temp. shelter in parking lot,

then 47 relocated to Hanokaa Hospital. ER stayed open.

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SUMMARY

Risk Hazards for hospitals reviewed Differences between Structural and Non-

structural damage at medical care facilities Reviewed several historical hospital evacuation

scenarios and lessons learned from them Examined some risks specific to the hospital

evacuation scenario, which merit planning, training, and exercise at your health care facilities

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References Santa Clara County Geneaology: Effects of the 1906 earthquake in San

Jose. http://www.sfgenealogy.com/santaclara/history/sc1906.htm Chavez CW, Binder B. A hospital as victim and responder: the

Sepulveda VA Medical Center and the Northridge EQ. J Emerg Med 14(4):445-54, 1996

Henry S. Mississauga Hospital: largest evacuation in Canada’s history. CMA Jour 122:582-586, 1980.

Koegler RR & Hicks SM. The destruction of a medical center by earthquake: Initial effects on patients and staff. Calif Med 116:63-67, 1972

Martchenke J , Pointer JE. Hospital disaster operations during the 1989 Loma Prieta EQ. Prehosp & Disast Med 9(3):146-153, 1994

Nates SL. Combined external and internal hospital disaster: impact & response in a Houston trauma center ICU. Crit Care Med 32:686-90, 2004

Norcross ED, et al. Impact of a major hurricane on surgical services in a university hospital. Am Surg 59(1):28-33, 1993

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References (cont’d) Olive View Medical Center photos:

http://earthquake.usgs.gov/regional/states/events/1971_02_09_photos.php Sternberg E, Lee GC, Huard D. Counting crises: U.S. hospital evacuations,

1971-99. Prehospital & Disaster Medicine 2004; 19:(2): 150-157. Wolff, C. “Three patients die in hospital explosion,” New York Times, Sept. 2,

1993 Gima C. Tremors rattle isles: two earthquakes in succession hit the Big

Island the hardest http://starbulletin.com/2006/10/16/news/story04.html Adamski M. Kona facility has limited operations, but structure is deemed to

be stable http://starbulletin.com/2006/10/18/news/story05.html “East Hawaii medical centers respond to Sunday morning earthquake.”

http://www.hawaiireporter.com/story.aspx?c0b55e68-bc2e-4790-b8f6-d5a2b758314b