Transcript 3 - Mediterranean Emergency Medicine Congress

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:
– 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 in-patients 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 off-site
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
– 1 pediatric hospital
– 2 general hosp. (private)
– 1 general hosp. (county)
1 psychiatric hospital
2 trauma centers
1 veterens hospital
Results - Hospital Demographics
•
•
•
•
•
•
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
– 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
– 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
– 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
– Pay phones worked
– Cell phones worked sporadically
– Some land lines worked, then failed as
network jammed with calls
– Ham radios, ambulance radios, hand-held
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
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:
– 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.
– 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.