History of Health Care Facility Evacuations

1
History of Health Care Facility Evacuations
OSHA Training Institute Region IX University of
California, San Diego (UCSD) - Extension
2
If you wish to control the future, study the
past.
-Confucius (551 B.C. to 479 B.C.)
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

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

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

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

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

8
Main Building, Agnew State Hospital , Santa Clara
County, CA.
Built of unreinforced masonry, it collapsed in
the San Francisco EQ, April 18, 1906.
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
10
San Francisco Earthquake 1906
Mechanics Pavilion Makeshift hospital for EQ
victims and patients evacuated from St. Lukes
other hospitals
11
After the Earthquake came the fires.
12
Mechanics Pavilion being evacuated as fire
spreads towards it.
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
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.
15
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

16
Tasks to be Planned for Hospital Evacuations

• Warning of an impending threathow 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

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

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.
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 Canadas history. CMA Jour 122582-586, 1980.
20
When a wildfire threatens
21
When Wildfires threatened a hospital
Childrens 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/weekoffir
e/20031027-9999_7n27victims.html
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.
23
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

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.
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 0600

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
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

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
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.

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
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

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

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.

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)

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

37
Northridge, CA Earthquake -1994

• 6.7 M EQ at 0431 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 0600
  hrs.

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)

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
40
Medical office building, of recent construction,
reinforced concrete, fails during Northridge EQ,
Jan 17, 1994.
41
Sept. 2, 1993 a faulty respirator exploded in
the ICU, leading to 3 deaths and the evacuation
of 120 others.
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 lt 9 hours.

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.

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

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

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

47
Super Typhoon Pongsona, Guam December 2002

• Located 3,700 miles SW of Hawaii (other side of
  Intl 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

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

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.

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 0610 hrs and near 1100
hrs-Noon near Gulfport/Biloxi, MS gt80 of the
City of New Orleans flooded from levee breaks
Official death toll as of 3/7/06 1,422.
(includes gt1,000 in LA) Displaced gt1,000,000
people Area covered by disaster declaration
90,000 sq.mi.,
almost equals area
of UK.
51
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.ht
m
52
Hurricane Katrina Aug. 28, 2005

• 30 hospitals evacuated, accounting for 22,200
  hospital workers and 5,048 beds
• Accounted for gt145,000 inpatient admissions in
  2004

http//planning2.com/NewOrleansHospitalsKatrina.ht
m
53
Partial list of evacuated hospitals following
Katrina 9/5/05
VA Gulf Coast Veterans GULFPORT MS 39531 Closed,
Not Accepting Patients Chalmette Medical
Center CHALMETTE LA 70043 Evacuated Children's
Hospital NEW ORLEANS LA 70118 Evacuated Crosby
Memorial Hospital PICAYUNE MS 39466 Evacuated Heal
thsouth Specialty Hosp NEW ORLEANS LA 70127 Evacua
ted Healthwest Rehab Hospital GRETNA LA 70056 Eva
cuated Kenner Regional Medical Center KENNER LA 7
0065 Evacuated Kindred Hospital - New Orleans NEW
ORLEANS LA 70115 Evacuated LifeCare Hospital,
Chalmette CHALMETTE LA 70043 Evacuated LifeCare
Hospital, Baptist NEW ORLEANS LA 70115 Evacuated L
ifeCare Hospital, Kenner KENNER LA 70065 Evacuate
d Lindy Boggs Medical Center NEW
ORLEANS LA 70119 Evacuated Meadowcrest
Hospital GRETNA LA 70056 Evacuated Memorial
Medical Center NEW ORLEANS LA 70115 Evacuated Meth
odist Hospital NEW ORLEANS LA 70127 Evacuated New
Orleans Adolescent NEW ORLEANS LA 70118 Evacuated
River Oaks Hospital NEW ORLEANS LA 70123 Evacuat
ed St Charles General Hospital NEW
ORLEANS LA 70115 Evacuated Touro Infirmary NEW
ORLEANS LA 70115 Evacuated Tulane University
Hospital NEW ORLEANS LA 70112 Evacuated VA
Medical Center NEW ORLEANS LA 70112 Evacuated Med
Center of LA at N.O. NEW ORLEANS LA 70112 Evacuat
ed River Oaks Child Adolescent NEW
ORLEANS LA 70123 Evacuated Lakeside Hospital NEW
ORLEANS LA 70117 Evacuated
Courtesy of Planning 2.0 LLC, Franklin, TN
54
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
55
Kiholo Bay EQ
Ceiling tiles downed after EQ

56
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

57
Kiholo Bay EQ 2006

• Other evacuations and Hospital impacts
• Hale Hoola 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.

58
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

59
References

• Santa Clara County Geneaology Effects of the
  1906 earthquake in San Jose. http//www.sfgenealog
  y.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 Canadas history. CMA Jour 122582-586, 1980.
• Koegler RR Hicks SM. The destruction of a
  medical center by earthquake Initial effects on
  patients and staff. Calif Med 11663-67, 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 32686-90, 2004
• Norcross ED, et al. Impact of a major hurricane
  on surgical services in a university hospital. Am
  Surg 59(1)28-33, 1993

60
References (contd)

• 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.ht
  ml
• Adamski M. Kona facility has limited operations,
  but structure is deemed to be stable
  http//starbulletin.com/2006/10/18/news/story05.ht
  ml
• East Hawaii medical centers respond to Sunday
  morning earthquake.http//www.hawaiireporter.com/
  story.aspx?c0b55e68-bc2e-4790-b8f6-d5a2b758314b