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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 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 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, 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: 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.