Transcript Hospital Evacuation of Pediatric Patients After the

Implications of Hospital
Evacuation After the
Northridge Earthquake
Carl H. Schultz, MD
Professor of Emergency Medicine
UCI Medical Center
Introduction
 Hospitals throughout the world are at high
risk for serious damage from earthquakes.
 Yet virtually nothing is known about
evacuation of in-patients from such
facilities after a seismic event.
 The vast majority of disaster medical
literature addresses hospital evacuation
due to hurricanes, floods, fires, and
hazmat spills.
Introduction
 Problematic factors for
hospital evacuation
after earthquakes:
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Absence of warning
Determining structural
and functional status
Loss of elevators, power,
& communication
Damage to neighboring
hospitals
Evacuation of patients
from damaged structures
Introduction
 The Northridge earthquake provided the
opportunity to study the evacuation of inpatients from several hospitals damaged
simultaneously by a seismic event.
 This is the largest project to date
evaluating off-site evacuation of inpatients from earthquake damaged
hospitals.
 Funded by a grant from the National
Science Foundation
Objectives
 Examine how decisions were made
regarding triage and the partial or
complete evacuation of the hospitals
 Identify the techniques used to move
patients within and between effected
facilities
 Describe the emergency management
strategies employed during the evacuation
Methods
 Observational retrospective investigation
 All acute care hospitals in Los Angeles
County which evacuated in-patients offsite as a result of the Northridge
earthquake
 Identified through records from L.A.
County Department of Health Services
and the State of California’s Office of
Statewide Health Planning and
Development
Methods
 Standardized survey instrument
 58 questions
 Reviewed by professional survey writer
 Various formats
• Scaled scoring (rate 1-5)
• Open ended. Participants
questionnaires not show stimuli for
answers.
• Yes/No
Methods
 Hospital administration recruited at least
one member from the following groups to
participate
 Physicians
 Nurses
 Administration
 Mechanical/facilities management
Methods
 Survey mailed to each hospital and
distributed to individuals for review
 Investigators then visited each hospital
and interviewed the participants in person
using the questionnaire
 All participants interviewed together
 Process required 2 hours
 Investigators recorded all responses by
participants
Methods
 All interviews conducted by the same
person
  score not needed
 Some interviews conducted by phone
 Involved one person
 Approved by Institutional Review Board at
Harbor-UCLA Medical Center
Results – Hospital Demographics
 166 medical facilities inspected for
earthquake damage in Los Angeles
 18 acute care hospitals
• 20% (91 hospitals total)
 25 Intermediate Care Facilities
 123 Nursing homes
 14 of 18 reported some form of patient
evacuation - horizontal or vertical (15%)
Results - Hospital Demographics
 8 hospitals (9%) reported off-site evacuations
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1 pediatric hospital
2 general hosp. (private)
1 general hosp. (county)
1 psychiatric hospital
2 trauma centers
1 veterens hospital
Results - Hospital Demographics
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Year built: 6 before 1973; 2 after 1973
No. of stories: 3(2), 5(1), 6(3), 8(2)
No. of patients: 74-334
No. of stairwells: 5-15
No. of elevators: 3-15
Types of specialized units: MICU,
CCU, NICU, PICU
Results - Evacuation Decision
6 hospitals evacuated in first 24
hours (immediate group)
 Initial evacuation decision
 Horizontal & vertical evacuation
decisions made by house supervisor or
spontaneously
 Off-site evacuation decision made by
Chief Hospital Administrator
 Damage assessment information used
by all institutions in decision-making
process
Results - Evacuation Decision
Immediate Group
 Both hospitals built after 1973 in this
group
 4 of the 6 hospitals were completely
evacuated, including the 2 post 1973
institutions
 2 hospitals condemned (pre 1973)
Results – Evacuation Decision
Reasons for Off-site Evacuation in Immediate
Group
6
5
4
3
2
1
0
Nonstructural
damage
Water loss
Can't
Power loss
Fear of
Structural
deliver care
aftershocks damage
Results - Evacuation Decision
2 hospitals evacuated after first 72
hours (delayed group)
 Initial evacuation decision
 Horizontal & vertical evacuation decisions
made by house supervisor or spontaneously
 Initial structure assessment negative
 Structural engineers change assessment in 3 and
14 days respectively
 Off-site evacuation decision made by Chief
Hospital Administrator
 Both hospitals completely evacuated and
condemned
Results - Evacuation Decision
Delayed Group
 Both hospitals built before 1973
 Possible reasons for change in status
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Damage always present, just missed
Damage progressed with aftershocks
Damage always present but difference of
opinion on its severity
Politics
 Note: Patients from 2 institutions in immediate
group evacuated to hospital in delayed group,
and then forced to evacuate again
Results - Evacuation Decision
Triage
 Immediate group
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4 of 6 felt no urgency to evacuate
• Used standard triage protocols
(sickest first)
2 felt evacuation urgent - 1 used scoop
and run (no triage protocol), 1 moved
healthiest patients first
 Delayed group - standard triage
Results - Evacuation Techniques
 Patients moved using backboards, walking,
wheelchairs, blankets, sheets. Stairs only
 Did not use special equipment such as
stair chairs, slides, etc. Felt unnecessary
 Personnel shortages
 3 reported staff reductions of 20-50%
• Would not leave families, roads out

Staff remained on duty to compensate
• Skill mix suffered
Results - Evacuation Techniques
 All hospitals performed horizontal &
vertical evacuations
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Damaged floors to undamaged floors
From one side of hospital to another
To other hospital locations
• ED, parking lot, cafeteria, SNF
 4 of 6 hospitals sent children home

Parents came in spontaneously or were
called
Results - Evacuation Management
 Immediate group - selection of off-site
hospitals for evacuated patients
 1 used MAC (Medical Alert Center)
exclusively (central control).
 4 used local network (independent)
 1 used both methods
 No difference in evacuation time
 Delayed group - selection of off-site
hospitals for evacuated patients
 1 used MAC and 1 used local network
Results –Evacuation Management
 Transportation
 6 of 8 hospitals used the MAC to obtain
transportation vehicles
 1 used local news agency (helicopter)
 1 hospital (delayed group) used local
EMS network (fire departments)
 Patient tracking
 No hospital had problems transferring
medications & records with patients
Results – Evacuation Management
 No problems getting other hospitals to
accept patients (no financial triage)
 Personnel sent with NICU, ICU, and
psychiatric patients.
 Psych patients remained under control
of transferring hospital
 No associated morbidity or mortality
 3 deaths not related to quake or
evacuation
Results – Evacuation Management
 Communications - not completely fail
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Pay phones worked
Cell phones worked sporadically
Some land lines worked, then failed as
network jammed with calls
Ham radios, ambulance radios, handheld radios
 All evacuations relied on functioning
communications
Results – Evacuation Management
Distance
from
Epicenter
(miles)
Modified
Mercalli
Intensities
(MMI)
Peak
Ground
Acceleration
(% Gravity)
Condemned
Hospital #1
0.8
VIII
79.6
No
Hospital #2
4.0
IX
89.4
No
Hospital #3
4.0
VIII
93.4
Yes
Hospital #4
6.7
VIII
74.3
No
Hospital #5
9.5
VIII
81.4
No
Hospital #6
12.9
VIII
59.0
Yes
Hospital #7
21.5
VII
46.1
Yes
Hospital #8
21.8
VII
46.1
Yes
STUDY
HOSPITALS
Results – Evacuation Management
Distance
from
Epicenter
(miles)
Modified
Mercalli
Intensities
(MMI)
Peak
Ground
Acceleration
(% Gravity)
Condemned
Hospital #A
2.8
VIII
49.3
No
Hospital #B
8.4
VIII
51.3
No
Hospital #C
12.7
VII
34.3
No
Hospital #D
13.0
VIII
60
No
Hospital #E
15.3
VI
37.5
No
Hospital #F
16.7
< VI
19.9
No
Hospital #G
17.3
VII
27.5
No
Hospital #H
22.8
VI
13
No
CONTROL
HOSPITALS
Hospitals without
structural damage
Epicenter
Hospitals scheduled
for demolition
Results – Evacuation Management
Epicenter distance
 Hospital closure from structural damage
had no statistically significant association
with distance from the epicenter in the
near field.
 The mean epicenter-to-hospital distance:
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Condemned facilities = 15.1 miles (95% CI 1.6
to 28.5)
Non-condemned facilities is 10.8 miles (95% CI
6.6 to 15.0)
The difference in the means is -4.2 (95% CI
-13.0 to 4.5)
Results – Evacuation Management
Peak Ground Acceleration
 Hospital evacuation had a statistically
significant association with peak ground
acceleration in the near field.
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Study hospital mean PGA = 0.71g (95% CI 0.56
to 0.87)
Control hospital mean PGA = 0.39g (95% CI
0.27 to 0.52)
The difference in means is 0.32g (95% CI 0.14
to 0.50) and is statistically significant.
Conclusion
 Moderate earthquakes cause damage to
hospitals that is severe enough to require
evacuation
• Post 1973 building code standards provide
insufficient protection
• Serious structural damage may not be
evident immediately
• Evacuating patients to hospitals within the
disaster zone may be unwise
Conclusion
 Patients can be evacuated safely from
earthquake-damaged hospitals using
available staff and equipment
 Special slides, chairs, etc are not necessary
 Distance from the epicenter is not absolutely
predictive of serious structural damage,
hospital evacuation, and demolition.
 Peak ground acceleration measurements
are a better predictor of hospital damage
Conclusion
 Evacuation can be coordinated by a
central EOC or independently by the
affected facility
 Hospitals should have a secondary
evacuation plan that functions in the
absence of central control
 A back-up plan should be in place that
provides care for patients in case
hospitals are rendered non-functional.