osha training institute 1 evacuation: challenges, principles and methods of safe egress osha...
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OSHA Training Institute 1
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