The Hospital Response After an Earthquake

1. The Hospital Response After an Earthquake Carl H. Schultz, MD Professor of Emergency Medicine Director, Disaster Medical Services UC Irvine School of Medicine

2. Introduction • Current research suggests earthquakes of magnitude 7.0 or larger occur on the Jordan Valley segment of the Dead Sea Fault about every 1000 years • The last major earthquake occurred in 1033 • Jerusalem located less than 40 km from the fault

5. Introduction • Estimate of worst-case event: • Moment magnitude 7.5 earthquake on the Jordan Valley segment • 30 billion dollars U.S. in economic losses

6. Introduction • Hospitals are vulnerable • 1971 San Fernando earthquake (Los Angeles, California, USA ) • 50 of 64 deaths due to hospital collapse • 4 hospitals with structural failure were closed

10. Introduction • 1994 Northridge earthquake(Los Angeles, California, USA) • 8 hospitals evacuated patients • 6 completely • 4 of these closed and demolished • 1995 Hanshin-Awaji earthquake(Kobe, Japan) • 13 hospitals partially or totally destroyed

12. Introduction • Delayed hospital closures can occur days to weeks after event • 2 hospitals closed 3 and 14 days after quake • Inspections not perfect • Red, yellow, and green tags • Based on objective and subjective criteria • ATC 20-1 • Political and financial considerations are involved

13. Introduction • Office of Statewide Health Planning and Development, State of California, 2001 • 48% of California’s hospital buildings are at high risk for collapse or loss of function from structural failure after a Northridge magnitude event • 91% of nonstructural components essential to safety and patient care will fail or sustain serious damage • Rand Corporation 2007 • 305 acute care hospitals have buildings vulnerable to collapse. ½ will be condemned by the 2013 deadline due to failure to retrofit • Cost of seismic improvements: $110 billion U.S.

14. Initial assessment Hospital Regional Hospital is functional Convergence behavior Personnel (staff) Equipment (stuff) Facilities (structure) Standard of care Hospital is non-functional Triage Internal patient evacuation Off-site patient evacuation Communication Staff behavior Government assistance Overview of Hospital Response

15. Initial Hospital Assessment • Immediate status of environment • Performed by Charge Nurse • Manual ventilation of patients • Threats to patient safety • Evacuate to safer area of unit • Contact House Supervisor and report status

16. Initial Hospital Assessment • House supervisor - makes initial assessment (hospital intact, partial damage, evacuation needed) • Assessment from patient care staff • Assessment from maintenance staff • Activates disaster plan • Implements hospital incident management system • Communicate with hospital director (if possible)

18. Initial Hospital Assessment • Need basic tool for rapid assessment of structural safety • Building inspectors may take 6-12 hours to arrive • ATC-20-1 http://www.atcouncil.org/Merchant2/merchant.mv?Screen=CTGY&Category_Code=a201 • Assess not-structural components (plumbing, heating/air conditioning, generators, water supply)

20. Initial Regional Assessment • Ideal metric – available quickly, identifies all areas of damage, easily disseminated • Traditional approach • Identification of epicenter • Measurement of moment magnitude • Richter scale • Reconnaissance • Systematic verbal reports from responders, government workers • Modified Mercalli Scale

21. Initial Regional Assessment • Epicenter • Point on the earth’s surface overlying the where the fault rupture begins (hypocenter) • Not the area of greatest shaking • Advantages • Available quickly • Gives general location of the earthquake • Disadvantages • Not provide specific information on areas of significant shaking and damage

22. Initial Regional Assessment • Moment magnitude • Measures overall energy release • Advantages • Gives a general measure of damage potential • Disadvantages • Poor predictor of shaking and damage at any one location • Energy not radiate out symmetrically

23. Initial Regional Assessment • Reconnaissance • Helicopters, spontaneous reports • Advantages • Available quickly • Disadvantages • Large sampling error • ? reliability • Many areas with significant damage are not readily apparent from the air

24. Initial Regional Assessment • Systematic reports • Government employees, typically postal workers, provide assessment of degree of shaking and observed damage • Use the Modified Mercalli Scale • Advantages • Gives fairly accurate assessment of damage distribution • Disadvantage • Slow • Difficult to distribute the information

25. Modified Mercalli Scale

28. Initial Regional Assessment • Any of these measure qualify? • NO. • What does? • Instrumental intensities • Peak ground velocity and peak ground acceleration are plotted as Shakemaps • Available within minutes of an earthquake • Can be downloaded by anyone from the internet • Easily interpreted by non-seismologists

29. Instrumental Intensity

32. Initial Regional Assessment • Shakemaps can depict the degree of ground shaking • Can this actually work and can it also assess risk for injuries and death? • YES • Data? • Epidemiologic • Ramirez, Peek-Asa: Epidemiology of Traumatic Injuries from Earthquakes. Epidemiol Rev 2005 • Peak ground acceleration was highly predictive • Distance from the epicenter in the Northridge quake was a poor predictor of injury and death

33. Initial Regional Assessment • Disaster Medicine • Schultz, Koenig, Lewis: Decision-making in Hospital Earthquake Evacuation: Does Distance from the Epicenter Matter? Ann Emerg Med 2007 (in press) • No significant difference in distance from the epicenter for evacuated and non-evacuated hospitals • Statistically significant difference in peak ground acceleration measurements between both groups of hospitals

35. 5 miles N

36. Initial Regional Assessment • Median distance from the epicenter for evacuated hospitals = 8.1 miles (13.5 km) • Median distance from the epicenter for control hospitals = 14.1 miles (23.5 km) • Difference in medians = 6 miles 95% CI: -4.8 to 11.9 miles Not statistically significant

37. Initial Regional Assessment • Median peak ground acceleration for evacuated hospitals = 0.77 g, where 1.0 g equals the force of gravity • Mean peak ground acceleration for control hospitals = 0.36 g • Difference in medians = 0.41 g 95% CI: 0.14 to 0.55 Statistically significant (p=0.009)

38. Initial Regional Assessment • Take home message: • Shakemaps are useful way to assess the risk of damage across the entire region of an earthquake • Are predictive of increased risk for building damage, injury, and death • Shakemap assessment by hospital personnel and emergency managers in the immediate aftermath of an earthquake needs to be included in the disaster plans of all vulnerable regions where such information is available

41. Hospital Is Functional • Prepare for patient convergence • Closest hospitals will receive most of the patients • Israel has real experience • Versailles nightclub collapse • Terrorist bombings • Earthquakes on larger scale • Credentialing of medical volunteers

42. Hospital Is Functional • Alternate sites of care • Parking lots • Temporary structures (tents) • Areas not used for patient care • Classrooms • Auditoriums • Early discharge of patients – problematic • Delivery of supplies/equipment • Agreement with vendors, Home Front Command

43. Hospital Is Functional • Change in standard of care? • Triage based on who receives care and who doesn’t • Delayed closure of lacerations • Use of ventilators • Admission to Intensive CareUnits (ICUs)

44. Hospital Is Not Functional • Triage Order of patient movement off unit: Sickest patients first • No immediate threat to safety (immediate building collapse unlikely) • Efficiency of movement not critical • Individuals use great deal of resources • Order of floor evacuation not matter

45. Hospital Is Not Functional • Triage • Order of patient movement off unit • Healthiest patients first • Immediate risk to safety (building collapse possible) • Efficiency of evacuation important • Can move more patients with less resources (some can evacuate themselves) • May need to leave trapped patients behind • Evacuation lower floors first

46. Hospital Is Not Functional • Internal patient evacuation • Movement of patients • Used gurneys, backboards, sheets, wheelchairs • Did not use specialized devices and would not use them if available • FLASHLIGHTS CRITICAL • Elevators will not work • Evacuation routes must only use stairs • Take patients charts and medications

47. Hospital Is Not Functional Off-site patient evacuation • Control of hospital evacuations • Traditional model • Emergency Operations Center (EOC) controls all aspects of patient transfer • Transportation assets Ambulances, helicopters • Destination decisions • How many patients go to which hospitals • Northridge model • EOC provides vehicles to hospitals per their request • EOC and hospitals share destination decisions

49. Hospital Is Not Functional • Northridge model (Schultz et al: New England Journal of Medicine, 2003) • 1066 patients evacuated totally, 818 in first day • How many people answering phones would it take for the EOC to coordinate the transfer of 800 patients in the midst of chaos? • Efficient use of time? • Other demands during first critical 24 hours • Use of shakemaps?

50. Hospital Is Not Functional • Outcome • EOC able to mobilize transportation assets • Used ambulances, buses, county vehicles • Very effective at this task • EOC can coordinate movement of some patients but not all • Hospitals can and will move patients on their own • Hospitals belonging to systems will be most effective • Recognition of hospital role should be part of disaster plan