Evacuation: Challenges, Principles and Methods of Safe Egress

1. Evacuation: Challenges, Principles and Methods of Safe Egress OSHA Training Institute – Region IX University of California, San Diego (UCSD) - Extension OSHA Training Institute

2. 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 OSHA Training Institute

3. Evacuation • Planning & Practice OSHA Training Institute

4. Risk Reality • All hazards approach • Evacuation can be from multiple causes • Intense focus on facilities’ ability to respond • Evacuation must be done in partnership OSHA Training Institute

5. 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 OSHA Training Institute

6. From Reactive to Planned OSHA Training Institute

7. Testing of Plans • Participation in exercises • Evaluations of exercises • Consideration of lessons learned from actual events • Adaptation of plans and equipment to modify plans OSHA Training Institute

8. 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 OSHA Training Institute

9. Evacuation of Large Numbers of Fragile Patients Hurricane Katrina 2005, Louis Armstrong Airport New Orleans OSHA Training Institute

10. 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 OSHA Training Institute

11. 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). OSHA Training Institute

12. HICS • Hospital Incident Command System (HICS) INCIDENT Commander Medical / Technical Specialist Liaison Officer Safety Officer Information Officer Logistics Finance Planning Section Operations Section Section Section OSHA Training Institute

13. 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 OSHA Training Institute

14. 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. OSHA Training Institute

15. 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 OSHA Training Institute

16. Options in Evacuations Actions: • Shelter in place • Horizontal or lateral movement • Vertical evacuation • Complete facility evacuation • The situation may require all methods OSHA Training Institute

17. 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 OSHA Training Institute

18. 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 OSHA Training Institute

19. 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 OSHA Training Institute

20. 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 OSHA Training Institute

21. 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 OSHA Training Institute

22. 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 OSHA Training Institute

23. Human Chain - Ambulatory Patients OSHA Training Institute

24. 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 OSHA Training Institute

25. Evacuation Devices & Employee Safety OSHA Training Institute

26. Evacuation Chairs and Hand Lifts OSHA Training Institute

27. Breakout Demonstrations • Disclaimer • Neither OSHA nor the presenters are advocating any products shown or demonstrated • These demonstrations are informational only OSHA Training Institute

28. 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 OSHA Training Institute

29. 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 OSHA Training Institute

30. 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 OSHA Training Institute

31. 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 OSHA Training Institute

32. Evacuation Literature • Evacuation of in-patients from hospitals after seismic events • Hospital evacuation from hurricanes, fires, floods, and hazmat spills OSHA Training Institute

33. 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 OSHA Training Institute

34. 1994 Northridge Earthquake Collapsed Parking Structure OSHA Training Institute

35. 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 OSHA Training Institute

36. 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 OSHA Training Institute

37. 1 Pediatric hospital 2 General hosp. (private) 1 General hosp. (county) 1 Psychiatric Hospital 2 Trauma centers 1 Veteran’s Hospital Hospital Evacuations 8 of 91 acute care hospitals evacuated (9%) • 6 within 24 hours (4 - complete & 2 partially) • 1 on day 3 structural damage • 1 on day 14 structural damage OSHA Training Institute

38. Evacuation Decisions during Northridge EQ • 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 OSHA Training Institute

39. Evacuation Decision • Immediate group • 4 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 OSHA Training Institute

40. Evacuation Techniques • Patients moved using backboards, walking, wheelchairs, blankets, sheets. Stairs only • No special equipment use • Personnel shortages of 20-50% at some hospitals OSHA Training Institute

41. 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 tracking • No difficulty with transferring medications & records with patients OSHA Training Institute

42. 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 OSHA Training Institute

43. Transportation of Patients • Private cars • Public buses • Hospital vans • Ambulances OSHA Training Institute

44. Evacuation • Communications intermittent but all evacuations relied on functioning communications • Pay phones, cell phones, intermittent landlines, ham radios, ambulance radios, hand-held radios OSHA Training Institute

45. 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 OSHA Training Institute

46. June 2001 Tropical Storm Allison OSHA Training Institute

47. 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 OSHA Training Institute

48. 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!” OSHA Training Institute

49. 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 OSHA Training Institute

50. 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 OSHA Training Institute