Lessons from Hurricane Katrina: A Risk Based Approach to Hospital Evacuation

1. Lessons from Hurricane Katrina:A Risk Based Approach to Hospital Evacuation Chris Johnson Boyd Orr: Julia Appleby, Peter Cooper, Andrew Foss, Stephen Hailey, Benjamin Jenks, Western Infirmary: Fouria Ashraf, Graham McKinlay, Chris McAdam, Jody Johnson, Martin Wilson University of Glasgow, Scotland. http://www.dcs.gla.ac.uk/~johnson

3. Strathclyde Fire Brigade. BFRL, US NIST.

5. Hurricane Katrina • Several precursors (Tropical Storm Alison). • East Jefferson General Hospital: • ad hoc evacuations of elderly patients; • waded from emergency department ramp; • elderly care home that was being inundated. • Clinicians and support staff at New Orleans’ University Hospital: • carry patients down 4 flights of stairs; • take them to an improvised ICU when generators flooded. • Chairman of medicine at Tulane University Hospital: • forced to use a colleague’s canoe; • coordinate with New Orleans’ University Hospital and Charity Hospital; • phone lines failed.

6. Hurricane Katrina • Investigations into multiple fatalities during evacuation of Memorial Medical Center. • Patients on 7th floor carried through hospital. • Many spent considerable time waiting for boat. • Hospital administrator said deaths due to ‘systems failure’. • Criticized lack of guidance on preparation for mass evacuations.

7. Legislation • International Building Code in 40+ US states - show “construction, size & character of means of egress” and numbers in each space. • OSHA - employers ‘ensure routes leading to exits are accessible and free from materials or items that would impede evacuation’. • UK Fire Precautions (Workplace) Regulations meet EC Directives 89/391 and 89/654 - employers responsible for outcome of adverse event. • Risk-based approach - must demonstrate any precautions are appropriate to the likelihood and consequences of any hazard. • Evacuation measures could be use to demonstrate mitigation of the potential consequences of an adverse event.

8. 2001 Department of Health • “NHS Trusts must have an effective fire safety management system” • They must “ensure emergency evacuation procedures for all areas and undertake fire risk assessments” • Specialist Fire Officers focus on “fire safety audit and fire risk assessments and assisting with reports to management”

9. But How Do We Do It? • There are few specialist techniques. • Risk assessment for fire: • Only consider evacuation as a mitigating factor? • Can we reason about risk of evacuation hazards? • Legislation is ambiguous in this area… • Slight change in emphasis, focus on evacuation • 1. consider risk of hazards that require evacuation; • 2. consider risks of conducting successful evacuation.

13. Plan of Munich Lowenbraukeller (April, 1973)

15. Evacuation of Summerland Bar, Isle of Man: • 51% use the entrance (37 guests, 1 staff member); • - 49% use emergency exit (23 guests, 14 staff).

16. Woolworths fire in Manchester: - 9 out of the 10 fatalities in canteen; - didnt leave before finishing or paying for meal?

17. Hospital Fires • Edleman et al (1980) study care home fire. • 95% (85) led down one staircase, 3 others available. • Normal route for staff and patients between floors. • Other 3 were evacuation routes with entry alarms. • Reluctance to use them even when fire justified it. • Evacuation longer than designer & Fire Officers think.

18. Brooklyn Fire • Fire breaks oxygen hoses treating patient. • Wall outlets now allow free-flow oxygen. • Smoke into hall and patient floor. • Must evacuate many bed-bound patients. • Nurses delay to close area valves: • residual pressure before treatment stops; • Could use back-up bottled oxygen; • But bottles create another fire hazard.

19. Virginia Fire • 5 die, well designed building, well trained staff. • Less night staff, day staff very busy. • Alarm to fire dept out of service. • Main aim is patient care not fire safety? • Oxygen enriched environment. • Doors wedged open in many wards. • Smoke in ceiling space, fatality distribution. • No sprinkler system also a risk in itself.

20. Operating Room Fires • Joint Commission on Accreditation of Healthcare Organizations • 100-200 operating room fires each year in US. • Oxygen-enriched environment. • Ignition sources eg lasers and cautery units. • Evacuation risks for patients - ICU sedation. • Train for extinguishers in sterile environments.

21. Tropical Storm Alison • 3 hospitals close to new patients. • 2 evacuated most critical patients. • 1 hospital completely evacuated. • Shutting down 2000+ beds. • 500+ ICU beds for the City of Houston. • Alison also closed 1 of Houston’s 2 level I trauma hospitals - serves 4 million people.

23. Lack of Incident Reporting • But no national or Federal registers for these events. • Scots NHS reports fires involving death or serious injury to HSE. • Fires involving death, serious injury or serious damage to Dept of Health. • No information on less serious events or successful evacuations; • 1994-2001 only 6 reports. 5 involved smoking, 1 ‘willful’ fire raising. • Even for serious events, litigation prevents lessons from being learned. • Fire Officers rely on ‘war stories’, word of mouth in meetings and exercises. • Contrast with legal reporting requirements for device failure in healthcare.

24. US Hospital Fire Drills • 3 mock fire drills during a 6-week period. • Electrosurgical pencil ignites drape. • Staff remove cover from patient, • throw onto floor, use extinguisher. • Organisers then say fire spread. • Simulate move of intubated patients • OR bed with a bag-valve mask. • Pack wounds with sterile sponges; • e.g. don’t move anaesthesia machine. • Gridlock, rooms evacuate at same time.

25. US Hospital Fire Drills • Debrief sessions especially if problems. • poor emergency response checklist; • delays in backup if patient and anaesthetist ‘injured’ in exercise. • Anaesthetist evacuate by OR back door: • steep incline above a busy road; • Hospital posts signs on doors. • ‘Systemic’ problems: • hospital paging coordinates response; • announcements could not be heard; • staff leave posts to check; • No plans if it were damaged; • messenger post opened & buy radios.

26. Case Study Hospital

27. Horizontal Evacuation • Does movement create greater risks than hazard? • Check location of fire, secure refuge & exit route: • Refuges within 12 meters of each patient’s room; • 70 secs to move patient to place of safety; • 30 secs more for staff to return to patient’s room. • Patients in immediate danger moved first. • Non-ambulatory before mobile patient & visitors; • Wheelchair patients grouped together ; • Staff lead mobile patients in a single journey. • Patients must not impede emergency personnel. • 3 people, 5 mins to disconnect/reconnect units; • 15 mins, conscious patient bed to wheelchair.

28. But… • Wisconsin urges staff not to use ‘horizontal’ evacuation: • evacuations should move all patients outside the building; • ‘required, regardless of building construction’; • ‘may not use defend in place methodologies’ drills too; • use of patients in drills is optional. • Department of Health in Scotland: • “less annual fire training if risk assessment carried out”; • “fire safety training appropriate to duties of the staff”; • “at least annually for staff involved in patient evacuation”.

29. Limitations of Drills • Sustained Costs. • Limited Accuracy. • Short ‘Shelf Life’. • Lack of Design Focus. • Danger. • Poor Reliability.

34. Crowd Density and Velocity Thompson and Marchant (1995)

35. Simulation results: • over 20 runs; • Blocking exits; • Lower figures are SDs.

36. Faster evacuation under model conditions: • North exit closed and a long way to main exit; • BUT only one bottleneck/door to main exit.

39. Modelling Nurse Behaviour • Coding of nursing staff behavior based on concurrent threads. • program creates an independent process for each individual. • Communication through a form of message passing; • Reactive route finding for each nurse using A* algorithm: • Simulated nurse ranks each possible moves from their current location; • Only go on to consider the next set of available moves from the top ranked adjacent position; • planned route gradually grows by always picking best next step for further consideration; • if potential route blocked then consider second route in the list of preferences. • Algorithm depends on appropriate heuristic: • Euclidian distance or detailed information about hospital layout; • Recall: • nurses modeled as independent threads and • each uses own independent navigation strategy; • contention will occur if 2 nurses move 2 beds along narrow corridor. • Specialist negotiation algorithms needed to resolve bottleneck.

40. Patient Preparation and Evacuation

41. Simplifying Assumptions • Timings for equipment on one floor of a particular hospital. • No obstacles – is this likely in a busy ward? • Bed movement did not require complex rotations for sharp corners. • Beds movements depends on model and maintenance provided: • Beds approx. 1 meter (38 inches) by 2.2 metres (86 inches). • Wheelchairs 0.75 metres (30 inches) by 0.75 metres (30 inches). • However, there were several different models. • Some wheelchairs upholstered similar to a moveable armchair. • others were based around more conventional metal frames. • No smoke, no cumulative fatigue effects etc.

42. Input and Output to G-HES

44. Summary

45. Further Work • RPDN on evacuation response. • Emergency ingress not just egress.

47. Questions? Thanks are due to Julia Appleby, Peter Cooper, Andrew Foss, Stephen Hailey, Benjamin Jenks, Fouria Ashraf, Graham McKinlay, Chris McAdam, Jody Johnson, Martin Wilson...