Implications of Hospital Evacuation After the Northridge Earthquake Carl H. Schultz, MD Professor of Emergency Medicine UCI Medical Center

Implications of Hospital Implications of Hospital Evacuation After theEvacuation After the

Northridge EarthquakeNorthridge Earthquake

Carl H. Schultz, MDCarl H. Schultz, MD

Professor of Emergency MedicineProfessor of Emergency Medicine

UCI Medical CenterUCI Medical Center

IntroductionIntroductionHospitals throughout the world are at Hospitals throughout the world are at

high risk for serious damage from high risk for serious damage from earthquakes.earthquakes.

Yet virtually nothing is known about Yet virtually nothing is known about evacuation of in-patients from such evacuation of in-patients from such facilities after a seismic event.facilities after a seismic event.

The vast majority of disaster medical The vast majority of disaster medical literature addresses hospital literature addresses hospital evacuation due to hurricanes, floods, evacuation due to hurricanes, floods, fires, and hazmat spills.fires, and hazmat spills.

IntroductionIntroductionProblematic factors for Problematic factors for

hospital evacuation after hospital evacuation after earthquakes:earthquakes: Absence of warningAbsence of warning Determining structural and Determining structural and

functional statusfunctional status Loss of elevators, power, & Loss of elevators, power, &

communicationcommunication Damage to neighboring Damage to neighboring

hospitalshospitals Evacuation of patients Evacuation of patients

from damaged structuresfrom damaged structures

IntroductionIntroduction

The Northridge earthquake provided the The Northridge earthquake provided the opportunity to study the evacuation of in-opportunity to study the evacuation of in-patients from several hospitals damaged patients from several hospitals damaged simultaneously by a seismic event.simultaneously by a seismic event.

This is the largest project to date This is the largest project to date evaluating off-site evacuation of in-evaluating off-site evacuation of in-patients from earthquake damaged patients from earthquake damaged hospitals.hospitals.

Funded by a grant from the National Funded by a grant from the National Science FoundationScience Foundation

ObjectivesObjectives

Examine how decisions were made Examine how decisions were made regarding triage and the partial or regarding triage and the partial or complete evacuation of the hospitalscomplete evacuation of the hospitals

Identify the techniques used to Identify the techniques used to move patients within and between move patients within and between effected facilitieseffected facilities

Describe the emergency Describe the emergency management strategies employed management strategies employed during the evacuationduring the evacuation

MethodsMethodsObservational retrospective investigationObservational retrospective investigationAll acute care hospitals in Los Angeles All acute care hospitals in Los Angeles

County which evacuated in-patients off-County which evacuated in-patients off-site as a result of the Northridge site as a result of the Northridge earthquakeearthquake Identified through records from L.A. Identified through records from L.A.

County Department of Health Services County Department of Health Services and the State of California’s Office of and the State of California’s Office of Statewide Health Planning and Statewide Health Planning and DevelopmentDevelopment

MethodsMethodsStandardized survey instrumentStandardized survey instrument

58 questions58 questions Reviewed by professional survey writerReviewed by professional survey writer Various formatsVarious formats

•Scaled scoring (rate 1-5)Scaled scoring (rate 1-5)•Open ended. Participants Open ended. Participants questionnaires not show stimuli for questionnaires not show stimuli for answers. answers.

•Yes/NoYes/No

MethodsMethodsHospital administration recruited at Hospital administration recruited at

least one member from the least one member from the following groups to participatefollowing groups to participate PhysiciansPhysicians NursesNurses AdministrationAdministration Mechanical/facilities managementMechanical/facilities management

MethodsMethodsSurvey mailed to each hospital and Survey mailed to each hospital and

distributed to individuals for reviewdistributed to individuals for review Investigators then visited each hospital Investigators then visited each hospital

and interviewed the participants in and interviewed the participants in person using the questionnaireperson using the questionnaire All participants interviewed togetherAll participants interviewed together Process required 2 hoursProcess required 2 hours Investigators recorded all responses Investigators recorded all responses

by participantsby participants

MethodsMethods

All interviews conducted by the All interviews conducted by the same personsame person score not neededscore not needed

Some interviews conducted by Some interviews conducted by phonephone Involved one personInvolved one person

Approved by Institutional Review Approved by Institutional Review Board at Harbor-UCLA Medical Board at Harbor-UCLA Medical CenterCenter

Results – Hospital Results – Hospital DemographicsDemographics

166 medical facilities inspected for 166 medical facilities inspected for earthquake damage in Los Angelesearthquake damage in Los Angeles 18 acute care hospitals18 acute care hospitals

20%20% (91 hospitals total)(91 hospitals total) 25 Intermediate Care Facilities25 Intermediate Care Facilities 123 Nursing homes123 Nursing homes

14 of 18 reported some form of 14 of 18 reported some form of patient evacuation - horizontal or patient evacuation - horizontal or vertical (vertical (15%)15%)

Results - Hospital Results - Hospital DemographicsDemographics8 hospitals (8 hospitals (9%) reported off-site evacuations9%) reported off-site evacuations

1 pediatric hospital 1 pediatric hospital 1 psychiatric hospital 1 psychiatric hospital 2 general hosp. (private) 2 trauma centers2 general hosp. (private) 2 trauma centers 1 general hosp. (county) 1 veterens hospital1 general hosp. (county) 1 veterens hospital

Results - Hospital Results - Hospital DemographicsDemographics

Year builtYear built: 6 before 1973; 2 after : 6 before 1973; 2 after 19731973

No. of storiesNo. of stories: 3(2), 5(1), 6(3), 8(2): 3(2), 5(1), 6(3), 8(2)No. of patientsNo. of patients: 74-334: 74-334No. of stairwellsNo. of stairwells: 5-15: 5-15No. of elevatorsNo. of elevators: 3-15: 3-15Types of specialized unitsTypes of specialized units: MICU, : MICU,

CCU, NICU, PICUCCU, NICU, PICU

Results - Evacuation Results - Evacuation DecisionDecision

Initial evacuation decisionInitial evacuation decision Horizontal & vertical evacuation Horizontal & vertical evacuation

decisions made by house decisions made by house supervisor or spontaneouslysupervisor or spontaneously

Off-site evacuation decision made Off-site evacuation decision made by Chief Hospital Administratorby Chief Hospital Administrator Damage assessment information Damage assessment information

used by all institutions in used by all institutions in decision-making processdecision-making process

6 hospitals evacuated in first 6 hospitals evacuated in first 24 hours (immediate group)24 hours (immediate group)


Both hospitals built after 1973 Both hospitals built after 1973 in this groupin this group

4 of the 6 hospitals were 4 of the 6 hospitals were completely evacuated, completely evacuated, including the 2 post 1973 including the 2 post 1973 institutionsinstitutions

2 hospitals condemned (pre 2 hospitals condemned (pre 1973)1973)

Immediate GroupImmediate Group

Results – Evacuation Results – Evacuation Decision Decision Reasons for Off-site Evacuation in Reasons for Off-site Evacuation in Immediate GroupImmediate Group

0

1

2

3

4

5

6

Non-structuraldamage

Water loss Can't deliver care

Power loss Fear ofaftershocks

Structuraldamage


Initial evacuation decisionInitial evacuation decision Horizontal & vertical evacuation decisions Horizontal & vertical evacuation decisions

made by house supervisor or made by house supervisor or spontaneouslyspontaneously

Initial structure assessment negativeInitial structure assessment negative Structural engineers change assessment in 3 Structural engineers change assessment in 3

and 14 days respectively and 14 days respectively Off-site evacuation decision made by Chief Off-site evacuation decision made by Chief

Hospital AdministratorHospital Administrator Both hospitals completely evacuated and Both hospitals completely evacuated and

condemnedcondemned

2 hospitals evacuated after 2 hospitals evacuated after first 72 hours (delayed group)first 72 hours (delayed group)


Both hospitals built before 1973Both hospitals built before 1973Possible reasons for change in statusPossible reasons for change in status

Damage always present, just missedDamage always present, just missed Damage progressed with aftershocksDamage progressed with aftershocks Damage always present but difference of Damage always present but difference of

opinion on its severityopinion on its severity PoliticsPolitics

Note: Patients from 2 institutions in Note: Patients from 2 institutions in immediate group evacuated to hospital in immediate group evacuated to hospital in delayed group, and then forced to evacuate delayed group, and then forced to evacuate againagain

Delayed GroupDelayed Group


Immediate groupImmediate group 4 of 6 felt no urgency to evacuate4 of 6 felt no urgency to evacuate

•Used standard triage protocols Used standard triage protocols (sickest first)(sickest first)

2 felt evacuation urgent - 1 used 2 felt evacuation urgent - 1 used scoop and run (no triage protocol), scoop and run (no triage protocol), 1 moved healthiest patients first1 moved healthiest patients first

Delayed group - standard triageDelayed group - standard triage

TriageTriage

Results - Evacuation Results - Evacuation TechniquesTechniques

Patients moved using backboards, walking, Patients moved using backboards, walking, wheelchairs, blankets, sheets. Stairs onlywheelchairs, blankets, sheets. Stairs only Did not use special equipment such as Did not use special equipment such as

stair chairs, slides, etc. Felt unnecessarystair chairs, slides, etc. Felt unnecessaryPersonnel shortagesPersonnel shortages

3 reported staff reductions of 20-50%3 reported staff reductions of 20-50%•Would not leave families, roads outWould not leave families, roads out

Staff remained on duty to compensateStaff remained on duty to compensate•Skill mix sufferedSkill mix suffered

Results - Evacuation Results - Evacuation TechniquesTechniques

All hospitals performed horizontal All hospitals performed horizontal & vertical evacuations& vertical evacuations Damaged floors to undamaged floorsDamaged floors to undamaged floors From one side of hospital to anotherFrom one side of hospital to another To other hospital locationsTo other hospital locations

•ED, parking lot, cafeteria, SNFED, parking lot, cafeteria, SNF4 of 6 hospitals sent children home4 of 6 hospitals sent children home

Parents came in spontaneously or Parents came in spontaneously or were calledwere called

Results - Evacuation Results - Evacuation ManagementManagement

Immediate group - selection of off-site Immediate group - selection of off-site hospitals for evacuated patientshospitals for evacuated patients 1 used MAC (Medical Alert Center) 1 used MAC (Medical Alert Center)

exclusively (central control). exclusively (central control). 4 used local network (independent)4 used local network (independent) 1 used both methods1 used both methods No difference in evacuation timeNo difference in evacuation time

Delayed group - selection of off-site Delayed group - selection of off-site hospitals for evacuated patientshospitals for evacuated patients 1 used MAC and 1 used local network1 used MAC and 1 used local network

Results –Evacuation Results –Evacuation ManagementManagement

TransportationTransportation 6 of 8 hospitals used the MAC to 6 of 8 hospitals used the MAC to

obtain transportation vehiclesobtain transportation vehicles 1 used local news agency (helicopter)1 used local news agency (helicopter) 1 hospital (delayed group) used local 1 hospital (delayed group) used local

EMS network (fire departments)EMS network (fire departments)Patient trackingPatient tracking

No hospital had problems transferring No hospital had problems transferring medications & records with patientsmedications & records with patients

Results – Evacuation Results – Evacuation ManagementManagement

No problems getting other hospitals No problems getting other hospitals to accept patients (no financial triage)to accept patients (no financial triage)

Personnel sent with NICU, ICU, and Personnel sent with NICU, ICU, and psychiatric patients. psychiatric patients. Psych patients remained under Psych patients remained under

control of control of transferringtransferring hospital hospitalNo associated morbidity or mortalityNo associated morbidity or mortality

3 deaths not related to quake or 3 deaths not related to quake or evacuationevacuation


Communications - not completely failCommunications - not completely fail Pay phones workedPay phones worked Cell phones worked sporadicallyCell phones worked sporadically Some land lines worked, then failed as Some land lines worked, then failed as

network jammed with callsnetwork jammed with calls Ham radios, ambulance radios, hand-Ham radios, ambulance radios, hand-

held radiosheld radiosAll evacuations relied on functioning All evacuations relied on functioning

communicationscommunications


Distance from

Epicenter (miles)

Modified Mercalli

Intensities (MMI)

Peak Ground Acceleration (% Gravity)

Condemned

STUDY HOSPITALS

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 #6 12.9 VIII 59.0 Yes

Hospital #7 21.5 VII 46.1 Yes

Hospital #8 21.8 VII 46.1 Yes


Distance from

Epicenter (miles)

Modified Mercalli

Intensities (MMI)

Peak Ground Acceleration (% Gravity)

Condemned

CONTROL HOSPITALS

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

Hospitals Hospitals without without structural structural damagedamage

EpicentEpicenterer

Hospitals Hospitals scheduled for scheduled for demolitiondemolition


Hospital closure from structural Hospital closure from structural damage had no statistically damage had no statistically significant association with distance significant association with distance from the epicenter in the near field. from the epicenter in the near field.

The mean epicenter-to-hospital The mean epicenter-to-hospital distance:distance: Condemned facilities = 15.1 miles (95% Condemned facilities = 15.1 miles (95%

CI 1.6 to 28.5) CI 1.6 to 28.5) Non-condemned facilities is 10.8 miles Non-condemned facilities is 10.8 miles

(95% CI 6.6 to 15.0)(95% CI 6.6 to 15.0) The difference in the means is -4.2 (95% The difference in the means is -4.2 (95%

CI CI -13.0 to 4.5)-13.0 to 4.5)

Epicenter distanceEpicenter distance


Hospital evacuation had a statistically Hospital evacuation had a statistically significant association with peak significant association with peak ground acceleration in the near field. ground acceleration in the near field.

Study hospital mean PGA = 0.71g (95% CI Study hospital mean PGA = 0.71g (95% CI 0.56 to 0.87) 0.56 to 0.87)

Control hospital mean PGA = 0.39g (95% CI Control hospital mean PGA = 0.39g (95% CI 0.27 to 0.52)0.27 to 0.52)

The difference in means is 0.32g (95% CI The difference in means is 0.32g (95% CI 0.14 to 0.50) and is statistically significant.0.14 to 0.50) and is statistically significant.

Peak Ground Peak Ground AccelerationAcceleration

ConclusionConclusion

Moderate earthquakes cause damage to Moderate earthquakes cause damage to hospitals that is severe enough to hospitals that is severe enough to require evacuationrequire evacuation• Post 1973 building code standards Post 1973 building code standards

provide insufficient protectionprovide insufficient protection• Serious structural damage may not be Serious structural damage may not be

evident immediatelyevident immediately• Evacuating patients to hospitals within Evacuating patients to hospitals within

the disaster zone may be unwisethe disaster zone may be unwise

ConclusionConclusionPatients can be evacuated safely from Patients can be evacuated safely from

earthquake-damaged hospitals using earthquake-damaged hospitals using available staff and equipmentavailable staff and equipment Special slides, chairs, etc are not Special slides, chairs, etc are not

necessarynecessaryDistance from the epicenter is not Distance from the epicenter is not

absolutely predictive of serious structural absolutely predictive of serious structural damage, hospital evacuation, and damage, hospital evacuation, and demolitiondemolition.. Peak ground acceleration measurements Peak ground acceleration measurements

are a better predictor of hospital damageare a better predictor of hospital damage

ConclusionConclusionEvacuation can be coordinated by a Evacuation can be coordinated by a

central EOC or independently by the central EOC or independently by the affected facilityaffected facility Hospitals should have a secondary Hospitals should have a secondary

evacuation plan that functions in evacuation plan that functions in the absence of central controlthe absence of central control

A back-up plan should be in place that A back-up plan should be in place that provides care for patients in case provides care for patients in case hospitals are rendered non-functional. hospitals are rendered non-functional.

Documents

Implications of Hospital Evacuation After the Northridge Earthquake Carl H. Schultz, MD Professor of Emergency Medicine UCI Medical Center