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Evacuation: Challenges, Principles and Methods of Safe Egress

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

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Objectives

Review the basics of evacuation Learn principles and methods of evacuation Identify key management plans in evacuation Discuss select events and lessons learned from

those events Recognize the complexity of employee safety

factors in evacuation

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Evacuation Planning & Practice

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Risk Reality

All hazards approach Evacuation can be

from multiple causes Intense focus on

facilities’ ability to respond

Evacuation must be done in partnership

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Importance of Planning

Planning should include: Emergency Preparedness Committees and

integration with region or operational area plans Identification of alternative locations Communications Transport options Cache of supplies or resources Employee safety and well-being

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From Reactive to Planned

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Testing of Plans

Participation in exercises

Evaluations of exercises

Consideration of lessons learned from actual events

Adaptation of plans and equipment to modify plans

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Lessons Learned from Events

Example: Hurricane Katrina Multiple hospitals evacuated simultaneously Fragile patients Few healthcare workers remained with

evacuated patients Healthcare workforce was displaced, lost homes

and jobs

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Evacuation of Large Numbers of Fragile Patients

Hurricane Katrina 2005, Louis Armstrong Airport New Orleans

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Nursing Home Patients

Increased need for wheelchairs, walkers, adult diapers, colostomy supplies and personal hygiene items, soft foods, clothing changes, portable oxygen and medicines. Hurricane Katrina 2005

Louis Armstrong Airport New Orleans

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Command Structure

Evacuation requires a command structure to best manage the situation

Safety of the patients, visitors and staff - All are at risk!

Coordination and tracking are needed Command systems vary by regions, country and

experiences A command structure model commonly used in

the U.S.A. is the Incident Command System (ICS).

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HICS

Hospital Incident Command System (HICS)

LiaisonOfficer

InformationOfficer

LogisticsSection

Planning Section

FinanceSection

OperationsSection

INCIDENTCommander

Medical / Technical Specialist

Safety Officer

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Staff Safety in Evacuations

“Staff health and safety while meeting the hospital’s medical mission are the highest priorities in responding to any type of incident.”

Incident Planning Considerations, Hospital Incident Command System (HICS) 2006

www.emsa.ca.gov/hics

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24 Seniors die on Evacuation Bus while preparing for Hurricane Rita

Defective brakes on an uncertified bus led to a mechanical fire, which is said to have rapidly spread within the bus due to oxygen cylinders aboard.

Standards of safety should not be ignored during evacuations.

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When Facilities are Impacted in the Emergency Event

Mass casualty events with incoming patients may occur concurrently with the need to evacuate

Hurricane Katrina was a prime example

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Options in Evacuations

Actions: Shelter in place Horizontal or lateral movement Vertical evacuation Complete facility evacuation The situation may require all methods

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Shelter-in-Place

Stay in the facility but minimize the hazardous impact

Example: distance from a hazardous spill, isolated fires, security breach

Bomb threat location Hostage situation

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Horizontal or Lateral Evacuations

Moving to other wings in the facility, beyond fire doors, into a safety zone

Easier movement of beds and equipment Faster in initial phases Further evacuation may not be necessary or

shelter-in-place option may be ordered

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Vertical Evacuations

Complex Cumbersome Increased physical risks Depending on cause for the evacuation,

elevators and escalators may be prohibited or out of operation

Evacuation devices (evacuation chairs and sleds) or manual carries may be required

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Complete Facility Evacuation Most evacuations

can be controlled In a controlled evacuation,

exit at direction of Incident Command Center, Fire or Police or authority in charge

Lateral / horizontal first Vertical second Evacuees can be staged in

outside areas to facilitate transport

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Facility and Utility Considerations

Evacuations may require rapid shut down of ventilation systems, power, water, gas and other infrastructure controls for the protection of everyone

Risks include: explosion, flooding, electrocution, toxic gases

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Who is Evacuated First?

Green - Walking Yellow - Chair assist Red - Full assist

The basic concept of triage in a disaster circumstance is to do the greatest good for the greatest number

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Human Chain - Ambulatory Patients

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Evacuation Devices or Hand Carries Use of evacuation devices is an option to

decrease the physical strain on employees and provide a safer means of transport for the patient

Devices require training Devices have weight limitations Manual carries may still be required

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Evacuation Devices & Employee Safety

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Evacuation Chairs and Hand Lifts

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Breakout Demonstrations

DisclaimerNeither OSHA nor the presenters are

advocating any products shown or demonstrated

These demonstrations are informational only

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Areas often Need a Specific Plan The nature of the patients or residents of the

facility may require more specific plans and techniques

Examples: Sensory impaired (sight, hearing) Specialty units: dialysis, operating rooms, ICUs,

psychiatric care, hyperbaric oxygen chambers Pediatrics facilities, NICU Extended care units Group homes

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Specific DepartmentalEvacuation Planning Example: Evacuation from the Operating

Room Cancellation of OR cases In evacuation procedures:

Stabilization and premature closure of case Airway management with alternative means Life support mechanisms Transport options from OR Management in alternative environment Transfer to stable environment

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Evacuation of the OR Patient

Know the routes and clear the corridor Gather transport stretchers & devices Conclude procedure as soon as possible Maintain life supports Maintain anesthetic state Take necessary meds with patient to continue

anesthesia during transport Control bleeding Sterile towels/covers over surgical sites

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Evacuation of the OR Patient

Remove intravenous solutions from poles - place in transport with the patient

Disconnect unnecessary leads, lines or other equipment

If time permits: Gather minimal number of instruments for transport Take additional intravenous solutions Secure equipment for transport

Don’t delay

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Evacuation Literature

Evacuation of in-patients from hospitals after seismic events

Hospital evacuation from hurricanes, fires, floods, and hazmat spills

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Review of Evacuation Events

1994 Northridge Earthquake, California 2001 Tropical Storm Allison, Houston, Texas 2001 Toulouse Hospital, France 2003 California Firestorm, San Diego, CA 2005 Hurricane Katrina, Louis Armstrong New

Orleans International Airport, New Orleans, Louisiana

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1994 Northridge Earthquake Collapsed Parking Structure

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Earthquakes - the Problems No warning Difficulty with rapid determination of structural or

infrastructure damage Situation changes with aftershocks, further

assessment questions and differences of opinion Loss of elevators, power, and communication Region impacted - damage to neighboring

hospitals Evacuation of patients from damaged structures

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Jan. 17, 1994 Earthquake

“Implications of Hospital Evacuation After the Northridge, California Earthquake”, describes a study of the evacuation of in-patients from Los Angeles County hospitals damaged simultaneously by a seismic event

CH. Schultz, K.K. Koenig, R. J. Lewis, New England Journal of Medicine, April 2003

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Hospital Evacuations

1 Pediatric hospital 2 General hosp. (private) 1 General hosp. (county)

1 Psychiatric Hospital 2 Trauma centers 1 Veteran’s Hospital

8 of 91 acute care hospitals evacuated (9%)6 within 24 hours (4 - complete & 2 partially)1 on day 3 structural damage1 on day 14 structural damage

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6 hospitals evacuated in first 24 hours (immediate group) and 2 after 72 hours (delayed)

Initial evacuation decisions made by house supervisor or spontaneously

Off-site evacuation decision made by Chief Hospital Administrator

All used damage assessment information in their decisions

Evacuation Decisions during Northridge EQ

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Evacuation Decision

Immediate group4 of 6 felt no urgency to evacuate and 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 - not urgent

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Evacuation Techniques

Patients moved using backboards, walking, wheelchairs, blankets, sheets. Stairs onlyNo special equipment use

Personnel shortages of 20-50% at some hospitals

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Evacuation Transportation & Tracking Transportation

6 of 8 hospitals used Emergency Operations Center

1 used local news agency (helicopter)1 used local EMS network (fire departments)

Patient trackingNo difficulty with transferring medications &

records with patients

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Evacuation

No Acceptance problems with evacuation (no financial triage)

Personnel were sent with NICU, ICU, and psychiatric patients, stable patients were not accompanied

Psych patients remained under control of transferring hospital

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Transportation of Patients

Private cars

Public buses

Hospital vans

Ambulances

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Evacuation

Communications intermittent but all evacuations relied on functioning communications

Pay phones, cell phones, intermittent landlines, ham radios, ambulance radios, hand-held radios

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Study Conclusions

Evacuation can be coordinated by a central Emergency Operations Center (EOC) or independently by the affected facility and had equal success

Should have a secondary evacuation plan in the absence of area EOC

Used no special devices

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June 2001 Tropical Storm Allison

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Tropical Storm Allison

Lessons Learned from a Hospital Evacuation during Tropical Storm Allison May 21, 2005 When tropical storm Allison stalled over

Houston releasing massive rainfall on Friday and Saturday June 8 and 9, 2001, the hospitals comprising the mammoth “ Texas Medical Center” flooded out, causing a challenging predicament for hospital staff and patients………………

Suburban Emergency Management Project. Biot #216

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Tropical Storm Allison

540 patients evacuated - no commercial or auxiliary power, ventilator patient hand pumped

699 patients - no water or air conditioning Closed ED and reduced census to 196 in 4

days; 17 patients remained in the ICU Children's - community plea for help - send

pumps, 30,000 research animals lost Taub General - only remaining Trauma Center Safety Message : “Be careful!”

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Solutions in Tropical Storm Allison

Pleas for RNs Hand ventilation Transfer staff to other hospitals Bring own food / water to hospital Paid employees regardless Fact Sheets Portable suction Hotel housing of workers, flyers delivered by

security to hotels & rooms

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Solutions

Scrubs and toiletries delivered to staff Emergency criteria planning for transfer 25 tons dry ice - to maintain specimens Fire marshals on each floor Temporary clinics in lobbies Satellite medical clinic at Astrodome Federal Response Teams

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Ammonium Nitrate Explosion Toulouse - France 21 Sept. 2001

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Ammonium Nitrate Explosion

Ten Dead in French Plant Blast The Associated Press, September 21, 2001 Toulouse, France (AP) – By Franck Demay “A huge explosion ripped through a

petrochemical plant Friday, blowing out windows across this southern French city. French television reported at least 10 dead and more than 200 injured, many seriously…………”

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Toulouse Accident Leading to Evacuations

Chemical reaction with sensitive industrial waste caused major explosion. Hugh cloud of dust and smoke.

Explosion blew out windows of businesses and

hospital, forcing evacuation.

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Explosion, Masks andConcern for Toxic Fumes

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Ranqueil Hospital

University linked hospital closest to site Damaged and initially evacuated Immediate inspection and repair started and

work resumed 435 victims received (1/4 admitted) 50 employees injured

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Impact on Healthcare Facility

Explosion caused windows to be blown inward at a healthcare facility close to the blast

Damage forced evacuation Conditions lead to potential for employee injury

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Evacuation

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Consequences

30 dead

3500 injured ( 50 serious)

862 taken to hospitals

Ultimately,1500 were seen at Ranqueil and Purpan Hospitals

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Austere Care & Medical Management

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Accountability & Movement Evacuation from any cause

requires accountability for patients and for staff

Family members who are with patients or staff in a crisis situation

Priority for relocation will depend on the stability of the patients and the resources available

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California Fires

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San Diego Firestorm - 2003

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Driven by Santa Ana Winds

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Fire Services Overwhelmed

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Medical Center Response

Activation of Hospital Emergency Incident Command System (HEICS)

Sunday afternoon Oct. 26 - 30, 2003Included all Command and General

Staff

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Critiques and Lessons Learned

Good background for the management of a large scale or large impact event on the system

Fresh look at impact of fire in canyon Need continued focus on emergency

preparedness and evacuation plans Need increased involvement of physicians in

planning, policy and development for emergency preparedness and response

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Critiques and Lessons Learned

Regional decisions to look closely at evacuation procedures

Establishment of a Medical Operations Center (MOC) that would coordinate with healthcare facilities in a crisis

MOC would coordinate with the County Emergency Operations Center

Re-evaluate radio communications needs

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Evacuation Routes and Visibility Restricted

Hospital staff were unable to get to the workplace, were greatly delayed, or evacuating their homes

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Hurricane Katrina 3rd major hurricane of 2005 and the first Category

5 storm of the season

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Evacuees

Airlifts and triage of evacuees during Hurricane Katrina 2005, Louis Armstrong New Orleans International Airport

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Patient Movement

Hospital patients and family evacuations during Hurricane Katrina 2005, New Orleans Airport

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Thousands to Evacuate

Complex problems Shortages of supplies, equipment and resources Minimal hospital staff were available to

accompany the evacuated patients It was necessary to triage evacuees based on

the clinical situation, urgency of evacuation and methods of available transportation

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Mass Movement New Orleans,

Hurricane Katrina Evacuees with health

problems examined in a triage area, main staging site, intersection of I-10 and Causeway, New Orleans

Evacuees in need of additional medical attention taken to outlying towns and cities with hospitals

August 31, 2005Photo credit-FEMA

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Special Considerations

Dialysis patients to dialysis centers Transplant cases Fresh post-surgical patients Requirements for oxygen Chemotherapy needs Psychiatric hospitalized patients Methadone and other drug rehab centers Exacerbation of chronic conditions without

medications

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Security Challenges in Evacuations Security staff in most hospitals are:

Private guards (hospital or contract) Unarmed and have no powers of arrest Expected to restrain violent patients or visitors or act

as deterrents Trend of minimal staffing and inadequate

coverage with a dependency on local law enforcement

Recurring Pitfalls in Hospital Preparedness and Response, Jeffrey N. Rubin January 2004

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Security Challengesin Evacuations

Facilities may need to make do with on site security

Law enforcement agencies may be overrun with urgent requests for multiple types of assistance and no prioritization

Training must include exercises and realistic planning and models

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Benchmarking for Hospitals Evacuations

United States National Science Foundation Study published 2005 Examined information available from 8 hospitals

impacted in the Northridge Earthquake Largest number of studied hospitals evacuated after a

single event and used to develop a standardized tool to gain information about evacuations

(Schultz 2003)

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Description of Disaster Plans in Studied Hospitals

Plans were varied and some addressed: Comprehensive plans Hospital as responder and victimContingency planningCommunity-wide planningEvacuation drills

(Schultz 2003)

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Limited Strategies

Tabletops only Vertical & horizontal evacuationsNo external evacuationsFew off site alternative facilities

No written agreementsReported verbal understandings to support

evacuation

(Schultz 2003)

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Summary

Evacuation requires planning Most evacuations are controlled Multiple resources are required Specific needs must be considered Departmental plans should be specific Employee and patient safety requires

training

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Summary Continued

Evacuations may need to include families and visitors

Accountability is important in considering the safety for all involved

Security will have to be managed internally at least in initial phases

Realistic training

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References

AORN Guidance Statement: Fire Prevention in the Operating Room, Standards, Recommended Practices, and Guidelines. 2005

DMAT San Diego CA-4 slides - Team selections Schultz CH,Koenig KL,Auf der Heide E., Olsen R.

Benchmarking for hospital evacuation: A critical data collection tool. Prehosp Disast Med 2005;20(5): 331–342

Schultz, CH, Koenig KK, Lewis RJ. Implications of hospital evacuation after the Northridge, California Earthquake in New England Journal of Medicine, April 2003

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References Continued

Rubin, JN. Recurring Pitfalls in Hospital Preparedness and Response January 2004

SEMP Biot #216: Lessons Learned from a Hospital Evacuation during Tropical Storm Allison May 21, 2005 http://www.semp.us/biots/biot_216.html

Socialstryreisen. The explosion in the artificial fertilizer factory in France 2001 - KAMEDO Report - 86