Assessment Report. Safe Hospitals in Emergencies and Hospitals Resilience to Climate Change

Transcription

1 Assessment Report Safe Hospitals in Emergencies and Hospitals Resilience to Climate Change Ha Van Nhu and Do Thi Hanh Trang Hanoi School of Public Health Ha Noi, December 2011

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3 This report was prepared by Ha Van Nhu, MD, PhD Head, Department of Disaster Management Hanoi School of Public Health Do Thi Hanh Trang, MPH Researcher, Department of Disaster Management Hanoi School of Public Health Disclaimer The analysis, results and recommendations in this report represent the opinion and views of the authors and are not necessarily representative of the position of Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH and World Health Organization (WHO). Ha Noi, December 2011 iii

4 ACKNOWLEDGMENT We would like to express our sincere thanks to the WHO and GIZ for their valuable technical and financial support in conducting this assessment. We also would like to extend our special thanks to health managers and health staff of the hospitals in the three provinces of Quang Ngai, Phu Yen and Bac Lieu, who participated in this assessment for their efforts to make this assessment accomplished. Finally, we would like to thank our colleagues at Hanoi School of Public Health for their contribution to different steps of the assessment from data cleaning to data entry and other administrative work. Without their support this assessment could not be conducted with success. 1

5 TABLE OF CONTENTS ACKNOWLEDGMENT BACKGROUND METHODOLOGY Design Site selection Assessment tool and variables Data collection Data management and data analysis RESULTS AND DISCUSSION Safe hospital indicators Structural indicators and architectural indicators of safe hospital Non-structural indicators related to lifelines facilities Medical and Laboratory Equipment Safety and security of people, equipment and supplies Functional Indicators of Safe Hospitals Complementary indicators related to energy efficiency, water conservation, waste management and preparedness for infectious disease outbreaks Energy Efficiency and water conservation Waste management Secure Food Supply Hospitals capacity for responding to increased infectious diseases Outbreaks CONCLUSIONS AND RECOMMENDATIONS Assessment of hospitals safety from disasters Structural safety Non-structural safety Functional safety Hospitals energy efficiency, water conservation, waste management and preparedness for infectious disease outbreaks Energy efficiency Water conservation

6 4.2.3 Waste management Hospitals capacity for responding to increased infectious disease outbreaks Methodological issues

7 1. BACKGROUND The Intergovernmental panel on climate change (IPCC) defines climate change as "a change in the state of the climate that can be identified (e.g. using statistical tests) by changes in the mean and/or the variability of its properties, and that persists for an extended period, typically decades or longer." The IPCC's Fourth Assessment Report (2007), states that climate change is unequivocal based on on-going scientific observations. Eleven of the 12 years between 1995 and 2007 were defined as being the warmest ever recorded (temperature recordings having begun in 1850). It is therefore apparent that there is a global change in climate and that certain countries will be affected more or less by these changes. The effects of climate change in Vietnam will be significant given its geography (large coastal and lowland region) and it's already frequent extreme weather events that have been increasing in magnitude over the years. Vietnam already experiences yearly flooding often causing costly damage to livelihoods and property, a situation that will certainly cause important economic losses and affect its development potential in the long term. Very few academic papers and reports focus on the issue of health and climate change in Vietnam despite the fact that the health sector will most certainly be greatly affected by global warming. "Climatic hazards bring both short- and long-term, direct and indirect health risks, including accident and injury, changes in exposure to vectors and pathogens, psychosocial effects, impacts on food supply and impacts on health care services" 1. In case of an emergency, the place that needs to be the most secure and prepared for a disaster is a hospital. A number of assessments focused on the structural and non-structural capacity of hospitals to respond in emergency situations have been carried out in a selected number of provinces in Vietnam 2. In addition, there are a number of tools specifically focused on healthcare facilities' sustainability and carbon footprint. Some of the indicators in these existing tools closely relate to the issue of climate change, and could therefore be included in a more climate-specific tool. However, new indicators need to be developed to complement the already existing ones. For this reason, the World Health Organization Vietnam, in cooperation with the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), were seeking to create an assessment toolkit for hospitals and healthcare facilities in order to measure their current preparedness to temperature increases, higher population exposure to vector-borne diseases (dengue, malaria, etc), water management and storage and accessibility of facilities during climate change-induced disasters. According to Part II, Section in the Socialist Republic of Vietnam's "National Strategy for the Protection, Care and Improvement of People's Health for the Period and Vision to 2030" it is stated that "it is recommended that a stable health service delivery model, assuring public health in settings of natural disasters should be developed and secured." 3 For this reason, 1 Few, R., Tran, P.G., Climatic hazards, health risk and response in Vietnam: Case studies on social dimensions of vulnerability. Global Environ. Change (2010), doi: /j.gloenvcha The World Health Organization in Vietnam supported an assessment of hospital emergency and disaster preparedness in Central Vietnam (Thua Thien- Hue, Quang Nam and Quang Ngai) carried out by the Hanoi School of Public Health and completed in May The assessments were done following WHO's Regional Office for the Western Pacific guidelines for "Safe Hospitals in Emergencies" (2009). 3 Socialist Republic of Vietnam. "National Strategy for the Protection, Care and Improvement of People's Health for the Period and Vision to 2030". Draft 6, May 2011 (Hanoi, Vietnam); p.28. 4

8 the time is now to start assessing healthcare centres' resilience, preparedness and sustainability in a changing climate. The Hanoi School of Public was commissioned by the WHO and GIZ to conduct a pilot project in three provinces namely Quang Ngai, Phu Yen and Bac Lieu, using the tools already developed by consultants in an earlier component of the project. The aim of the pilot is to assess preparedness to the increasing effects of climate change of the hospitals in the three study provinces in order to provide sufficient data and information on current gaps and opportunities for the improvement of healthcare in Vietnam. It also aims to test the appropriateness and applicability of the developed tool. 5

9 2. METHODOLOGY 2.1. Design The assessment will be based on a cross-sectional design, using both qualitative and quantitative methods Site selection The assessment will be conducted in the 3 provinces of Quang Ngai, Phu Yen, and Bac Lieu. These are provinces that are prone to meteo-hydrological hazards such as floods and typhoons. The name and number of hospitals in the three provinces are presented in the table below. Table 1. List of hospitals in the 3 studied provinces No Bac Lieu province Phu Yen province Quang Ngai province 1 Bac Lieu provincial general hospital 2 Gia Rai district general hospital 3 Phuoc Long district general hospital 4 Vinh Loi district general hospital 5 Hong Dan district general hospital 6 Dong Hai district general hospital 7 Hoa Binh district genderal hospital Phu Yen provicial general hospital Phu Yen provincial hospital of traditional medicine Phu Yen provincial hospital of nursing and rehabilitation Phu Yen provincial hospital of ophthalmology Tuy Hoa district general hospital Dong Xuan district general hospital Song Cau district general hospital 8 Thanh Vu private hospital Tuy An district general hospital 9 Son Hoa district general hospital 10 Phu Hoa district general hospital 11 Tay Hoa district general hospital 12 Dong Hoa district general hospital 13 Song Hinh district general hospital Quang Ngai provincial general hospital Duc Pho district general hospital Son Tinh district general hospital Ba To district general hospital Binh Son hospital district general Mo Duc district general hospital Ly Son district general hospital Minh Long district general hospital Nghia Hanh district general hospital Son Ha district general hospital Son Tay district general hospital Tay Tra district general hospital Tra Bong district general hospital 14 Tu Nghia district general hospital Total 8 hospitals 13 hospitals 14 hospitals 6

10 We assessed the resilience to climate change of all these hospitals except for Ly Son, Son Tay and Tay Tra district general hospitals in Quang Ngai province due to logistics constraints as this hospital is situated on isolated districts. Therefore, the total number of hospitals to be assessed was 33 (thirty three) hospitals Assessment tool and variables The assessment was undertaken based on indicators of a combined tool. This tool includes the tool kit developed by the Ministry of Health s Administrative Management Services. It applies specifically for assessing a healthcare facilities ability to ensure safe and continuous operation during an emergency including natural disaster. The other part of the assessment tool is a set of complementary indicators aimed to measure a healthcare facilities operations with regards to climate change mitigation initiatives that are directed towards reducing the health care carbon footprint and strengthening health care sustainable operations and resiliency, covering the topics of energy efficiency, water conservation, waste management and also aimed to measure the health facilities capacity to respond to infectious disease epidemics given that it is anticipated that incidences of certain types of diseases as well as new diseases or more complicated strains of existing diseases will increase as a result of climate change Data collection Data collection was undertaken within three weeks from mid of October. There was a national consultant and an assistant working in each province. Before the assessment team s visit to the hospitals, an official letter stating clearly the purpose and main activities of the assessment project was sent to the Provincial Department of Health of the three provinces. And then the Provincial Department of Health informed the hospitals of the assessment before the HSPH team s visit. A contact person from each provincial Department of Health was requested and worked as local supporter with the assessment team during both preparation activities and fieldwork. Structured interviews will be conducted based on the combined tool. Direct observation was also undertaken. A briefing session about the purpose of the assessment was organised at each hospital before the interviews. Hospitals managers and key staffs e.g. head or vice head of the Planning department and logistics department were invited to participate in the assessment. An electronic report of the assessment would be sent to each hospital once it is accomplished. Participation in the assessment was totally voluntary and oral consent was obtained from the participants. To ensure confidentiality, hospital names are be used in the assessment report so that individual hospitals cannot be identified. 7

11 2.5. Data management and data analysis All questionnaires/checklists were screened for missing or inconsistent information before being entered into the computer using Epi data software. Data cleaning was done again after data had been entered. Missing information was recollected via telephone or . After data had been entered, all records were transferred to STATA format and analysed using this software (version 10.0). Analyses in the report were mostly descriptive. Absolute numbers were used instead of percentage due to the limited number of hospitals involved in the assessment. 8

12 3. RESULTS AND DISCUSSION This section presents findings of the assessment together with discussion of their implication. The section includes two main parts corresponding to two main components of the assessment tools as already mentioned in the methods section. The first part deals with hospital s capacity to stay safe during emergencies and disasters. This part includes indicators that allow assessment of structural, non-structural and functional safety of hospitals. The second part deals with assessment of hospital resiliency to climate change with regards to energy efficiency, water conservation, waste management as well as ability to cope with infectious disease outbreaks Safe hospital indicators Structural indicators and architectural indicators of safe hospital Location The terrain where the health facility is located provides valuable clues as to the nature of the disaster that may be expected and/or other potential dangers from disasters (e.g landslides in slopes during typhoons). Identification of the location and any relevant hazards is essential to prompt proper measures to minimize damage to structures. 4 Data from the assessment show that about two thirds of the hospitals (21/33) have buildings not located in hazardous areas. 12 hospitals were built on flood and typhoon prone areas. Only 14 hospitals out of 33 hospitals have provisions for addressing the related hazards such as installment of small cement dykes or the construction of storm water drains. This means that even some hospitals are not considered as being located in a hazard prone area, measures to minimize damage to structures were still undertaken. It should be noted that in Quang Ngai province, only 4 out of 12 hospitals are located on a non-hazardous place and only 7 out of 12 hospitals have appropriate provisions for addressing hazards related to location. Table 2. Location Indicators Quang Ngai Phu Yen Bac Lieu Total Building is not located in a hazardous area Building have appropriate provisions for addressing hazards related to location 4/12 No 9/13 No 8/8 Yes 21/33 1/3 7/12 No 3/13 No 4/8 Yes 14/33 1/3 4 PAHO, Mitigation of Disasters, Volume 3, pp

13 Design Design of the hospitals building is also essential to ensure their ability to withstand natural disasters. A number of aspects of hospitals design were considered in the assessment (see table 3). From table 2, we can see that all buildings of all hospitals have a simple shape and are symmetrical and the number of building floors in all hospitals is appropriate to the area s construction planning. It should be noted that normally at district level and at provincial level (in less developed provinces where land area is still abundant) hospitals overall design often follows the Vietnam construction standards. In terms of building density, less than half of the hospitals (15/33) meet criteria building density is less than or equal to 35%. The number of hospitals that do not meet this criterion is extremely low in Phu Yen and Bac Lieu (3/13 and 2/8 respectively). This indicator is in line with the indicator of greenery area that must not be lower than 45% in the Vietnam construction standards. As none of the hospitals are situated on an earthquake prone area, the criteria about the building s seismic resistance are not applicable in the assessment. In a hospital it is expected that proper structures to provide access to persons with limited mobility are in place 5. However, only 16 out of 33 assessed hospitals have ramps put in appropriate areas for use by disabled people. Table 3. Design Indicators Quang Ngai Phu Yen Bac Lieu Total Building has a simple shape and is symmetrical Building density is less than or equal 35% Building in earthquake prone area has a seismic resistance level of 8 (MSK 64 seismic resistance scale) Ramps are present in appropriate areas for moving bed patients and for use by disabled people Number of building floors are appropriate to the area s construction planning 12/12 Yes 13/13 Yes 8/8 Yes 33/33 3/3 10/12 Yes 3/13 No 2/8 Yes 15/33 2/3 0/12 No 0/13 No 0/8 No 0/33 0/3 6/12 Yes 5/13 No 5/8 Yes 16/33 2/3 12/12 Yes 13/13 Yes 8/8 Yes 33/33 3/3 5 WHO Field manual for capacity assessment of health facilities in responding to emergencies WHO. 10

14 Structures The number of hospitals meeting structural criteria is presented in table 4 below. It can be seen that most of the hospital have structures built in accordance with Vietnam s construction standards (28/33). Although the number of hospitals reporting that their building structural members are strong enough to resist strong winds and earthquake is very high (27/33), this is a very subjective opinion. Furthermore the indicator does not indicate the strength of winds and earthquake that the building members can resist to. The number of hospitals meeting the remaining structural criteria is very low. Especially only one third of the hospitals reported that glass walls, doors and windows can resist wind speed level of 12, and only one provincial hospital meets this criterion. In Quang Ngai province, only one hospital meets this criterion. Windows and doors of most assessed hospitals are made of thin glass with aluminium frame that are not strong enough to resist to very high wind speed. Table 4. Structures Indicators Quang Ngai Phu Yen Bac Lieu Total No major structural cracks on structural members Structures built with fireresistant and nontoxic materials Structures built in accordance with Vietnam s construction standards Cabinets, shelves, appliances and equipment are properly anchored Building structural members are strong enough to resist strong winds and earthquake Glass walls, doors and window resist basic wind speed level of 12 (Vietnam wind speed forecast) 4/12 Yes 8/13 Yes 3/8 Yes 15/33 3/3 0/12 No 9/13 Yes 6/8 Yes 15/33 2/3 11/12 Yes 11/13 Yes 6/8 Yes 28/33 3/3 6/12 Yes 2/13 Yes 6/6 Yes 14/31 3/3 9/12 Yes 13/13 Yes 5/7 Yes 27/32 3/3 1/12 No 6/12 No 4/6 Yes 11/30 1/3 It was found from the assessment that all but one assessed hospital have complete set of design and as built construction drawings and have all necessary building permit as seen in Table 5. This is understandable as all assessed hospitals are public ones and the construction of the hospital must be approved by the people s committee at provincial or district level. One hospital in Quang Ngai could not present their design and construction drawings but it does not mean that it was built without a proper design and as-built construction drawings. This district hospital must have been approved by the district people s committee before being built. 11

15 Table 5. Permit and clearance Indicators Quang Ngai Phu Yen Bac Lieu Total Complete set of design and as-built construction drawings Complete with necessary building permits 11/12 Yes 13/13 Yes 8/8 Yes 32/33 3/3 11/12 Yes 13/13 Yes 8/8 Yes 32/33 3/ Architectural non-structural indicators There are several groups of indicators being used to assess the architectural strength of the hospital buildings. Safety of roofing Firstly indicators reflecting safety of roofing are presented in table 6. It can be seen that few hospitals have roofing design to withstand wind speed of level 12 (18/31), even two of the three provincial hospitals do not meet these criteria. For buildings located in cyclone-prone area, studies show that a roof angle of is optimum for withstanding wind forces 6. However, out of the 33 assessed hospitals, only 23 meet this criterion. This might be one of the reasons that decrease ability to withstand strong wind and storms of the buildings roofing. On the contrary, the situation of roofing drainage is good with the roof s drainage system of 31 out of 33 hospitals meeting Vietnam s construction standards and being regularly maintained. Table 6. Safety of roofing Indicators Quang Ngai Phu Yen Bac Lieu Total Roofing designed to withstand wind speed of 12 Roof s angle is less than 30 0 for buildings in wind or storm prone area Roof s drainage system is in accordance with Vietnam s construction standards and regularly maintained 4/12 No 10/12 No 4/7 Yes 18/31 1/3 8/12 Yes 9/13 Yes 6/8 Yes 23/33 3/3 12/12 Yes 13/13 Yes 6/8 Yes 31/33 3/3 6 Ian Davis and Satyedra P.Gupta, Technical Background Paper. In: Disaster Mitigation in Asia and the Pacific (Asian Development Bank, Manila),

16 Safety of ceiling Safety of ceiling also contributes to the hospitals ability to withstand natural disasters. However, data did not reveal a positive picture regarding this group of indicators as seen in Table 7. Ceiling s fire resistance seems to be a common limitation in the assessed hospitals because only 6 out of 27 hospitals have ceiling materials being coated and treated with fireretardant paint. And among the three provinces, the situation is worst in Quang Ngai province where for 3 out of 4 indicators (concrete ceilings have no cracks, ceiling materials are coated or treated with fire-retardant paint and ceiling liner or light fixtures properly fastened and supported), only 25% of the hospitals or less meet them. Table 7. Safety of ceiling Indicators Quang Ngai Phu Yen Bac Lieu Total Concrete ceilings have no cracks and leaks Drop ceilings made of materials other than concrete securely fastened Ceiling materials are coated or treated with fireretardant paint Ceiling liner or light fixtures properly fastened and supported 3/12 Yes 10/13 No 4/7 Yes 17/32 2/3 3/5 Yes 7/7 Yes 5/8 Yes 15/20 3/3 1/12 Yes 1/8 Yes 4/7 Yes 6/27 3/3 3/12 Yes 13/13 Yes 6/7 Yes 22/32 3/3 Safety of doors and entrances Safety of doors and entrances of hospitals buildings are assessed based on a range of indicators that are presented in table 8 below. Indicators with positive results include door securely attached to jambs, doors design follow Vietnam construction standard, rooms such as the operating room, intensive care unit, recovery room, delivery room, labour room, isolation rooms and other sterile areas have manual doors closers, and Locks installed on sleeping rooms can be locked only from the corridor to permit exit from room by a simple operation without a key. The numbers of hospitals satisfying these indicators are 28/32, 23/30, 30/31, and 25/32, respectively. Indicators with extremely negative results (i.e. that only one third of the hospitals or less meet) include doors materials are fire resistant, fire exit doors are fire-resistant, swing out with self-closing device, power-operated doors can be opened manually to permit exit in the event of power failure, automatic doors have manual overrides, and A door designed to be kept closed as a way out such as a door to a stair or horizontal exit and provided with a reliable self-closing mechanism and not secured in the one position and A door designed to be kept closed shall bear a sign such as: FIRE EXIT, KEEP DOOR CLOSED. The numbers of hospitals meet these indicators are 10/32, 13

17 2/20, 5/19, 4/22, 7/21 and 5/21, respectively. It can be seen that fire-resistance of doors have not been paid due attention by the assessed hospitals. Table 8. Safety of doors and entrances Indicators Quang Ngai Phu Yen Bac Lieu Total Door materials are windand fire resistant Doors securely attached to jambs Doors design follow Vietnam Construction standards Main doors are double swing, bathroom door is swing out, emergency room doors are swing in and out Fire exit doors fireresistant, swing out, with self-enclosing device Power-operated doors can be opened manually to permit exit in the event of power failure Automatic doors have manual overrides Rooms such as the operating room, intensive care unit, recovery room, delivery room, labour room, isolation rooms and other sterile areas have manual doors closers In high-rise buildings and structures, the interior vertical exit stairwell or staircase has a pressurized fire exit or smoke-proof fire exit suitably sealed against smoke, heat and fire Locks installed on sleeping rooms can be locked only from the corridor to permit exit from room by a simple operation without a key 1/12 No 5/13 No 4/7 Yes 10/32 1/3 10/12 Yes 11/13 Yes 7/7 Yes 28/32 3/3 7/11 Yes 12/13 Yes 4/6 Yes 23/30 3/3 7/12 Yes 6/13 Yes 4/7 No 17/32 2/3 0/8 No 1/5 No 1/7 No 2/20 0/3 1/10 No 1/2 No 3/7 Yes 5/19 1/3 1/12 No 1/3 No 2/7 Yes 4/22 1/3 11/12 Yes 13/13 Yes 6/6 Yes 30/31 3/3 1/11 Yes 7/10 Yes 2/5 Yes 10/26 3/3 12/12 Yes 9/13 Yes 4/7 No 25/32 2/3 14

18 Indicators Quang Ngai Phu Yen Bac Lieu Total A door designed to be kept closed as a way out such as a door to a stair or horizontal exit and provided with a reliable self-closing mechanism and not secured in the one position A door designed to be kept closed shall bear a sign such as: FIRE EXIT, KEEP DOOR CLOSED 1/11 Yes 3/4 No 3/6 Yes 7/21 2/3 1/11 Yes 2/4 No 2/6 Yes 5/21 2/3 Safety of windows and shutters Safety of windows and shutters in the assessed hospitals is rather good. For all three indicators windows have wind and sun protection devices, windows have features to secure the safety of the patient, and windows are leak proof, the number of hospitals satisfying the indicator is rather high, being 26/32, 22/31, and 27/32 respectively. Table 9. Safety of windows and shutters Indicators Quang Ngai Phu Yen Bac Lieu Total Windows have wind and sun protection devices Windows have features to secure the safety of the patient (e.g. grilles, railings) 10/12 Yes 11/13 No 5/7 Yes 26/32 2/3 9/12 Yes 8/13 No 5/6 Yes 22/31 2/3 Windows are leak proof 8/12 Yes 12/13 Yes 7/7 Yes 27/32 3/3 Safety of walls, divisions, partitions Regarding safety of walls, situation in Quang Ngai is extremely bad while none of the hospitals reported that the exterior walls meet the fire resistance rating of two hours. In the other two provinces, all but one hospital meet these criteria. Regarding safety of divisions and partitions, it should be noted that only about one third of the assessed hospitals have partitions. And few hospitals having partitions having them made of fire resistant construction materials (8/20). Again, this reflects a weakness in hospitals preparedness for fire-related hazards. Results of other indicators used to assess safety of divisions and partitions are presented in table

19 Table 10. Safety of walls, divisions, partitions Indicators Quang Ngai Phu Yen Bac Lieu Total Exterior walls meet the fire resistance rating of two hours Room partitions made of fire-resistant construction materials Compartments enclosed slab-to-slab, floor-to-floor and wall-to-wall Rooms may be subdivided provided that the arrangement allows for direct and constant visual supervision by nursing personnel 0/12 No 12/13 Yes 6/7 Yes 18/32 2/3 2/10 Yes 3/3 No 3/7 No 8/20 1/3 6/10 Yes 4/4 No 6/6 No 16/20 1/3 8/12 Yes 2/3 No 4/7 Yes 14/22 2/3 Safety of exterior elements (cornices ornaments, façade, plastering) Exterior elements such as ornaments, façade and plastering sometimes might not be considered in relation with the hospitals preparedness for emergencies. Fortunately, the situation regarding safety of these elements in all three provinces is rather good. Among 32 hospitals reporting having exterior elements, 31 hospitals said that their exterior elements are securely fastened to walls, 30 hospitals said that hanging light fixtures are properly anchored and 31 hospitals said that their electric wires and cables are properly fastened and secured. While anchoring and fastening of the element is good, the situation regarding fire resistance of plastering material is a bit less positive where only 23 out of 32 hospitals reported that their plastering material can resist fire within at least 20 minutes. Most of the hospitals not meeting this criterion were situated in Quang Ngai province as seen in table 11. Table 11. Safety of exterior elements (cornices ornaments, facade, plastering) Indicators Quang Ngai Phu Yen Bac Lieu Total Exterior elements securely fastened to walls Hanging light fixtures properly anchored Electric wires and cables properly fastened and secured Plastering material can be fire resistant within at least 20 minutes 11/12 Yes 13/13 Yes 7/7 Yes 31/32 3/3 11/12 Yes 12/13 Yes 7/7 Yes 30/32 3/3 12/12 Yes 13/13 Yes 6/7 Yes 31/32 3/3 5/12 No 12/13 Yes 6/7 Yes 23/32 2/3 16

20 Safety of floor coverings Some of the indicators reflecting safety of floor coverings in the MOH s tool are not familiar to both hospitals staff and assessments staffs. These are interior finish of walls and ceilings in any room or exit should be Class A according to the method of test of surface burning characteristics of building materials and floor finishing materials are class A or class B throughout the hospital, nursing home, residential or custodial care facilities. Therefore, these two indicators are not included in the assessment results. Other indicators of floor coverings safety are presented in table 12. Only half of the hospitals reported that floor interior finish has fire suppression system. High number of hospitals reported that they have nonslip floor materials without crevices in all clinical and service areas and easy-to-clean floor materials in all other nonclinical areas and reinforce and fire resistant concrete floor slabs. (26/32 and 29/32, respectively) Table 12. Safety of floor coverings Indicators Quang Ngai Phu Yen Bac Lieu Total Nonslip floor materials without crevices in all clinical and service areas and easy-to-clean floor materials in all other nonclinical areas Reinforce and fire resistant concrete floor slabs Interior finish with fire suppression system 6/12 No 13/13 Yes 7/7 Yes 26/32 2/3 10/12 Yes 13/13 Yes 6/7 Yes 29/32 3/3 0/12 No 12/13 Yes 4/7 No 16/32 1/ Non-structural indicators related to lifelines facilities Besides ceilings, doors, windows and floors, non-structural elements of a building also include lifeline facilities such as electricity, water, plumbing equipment and installations. For health facilities, attention needs to be paid to these non-structural elements, particularly medical equipment since they are necessary to its operations. Too much damage to these elements can cause its functional collapse and even lead to structural damage of buildings and physical injury to patients Electrical system For safety of its occupants, a hospital should have a reliable alternative source of power for emergency lighting and operation of essential equipment. If this is unavailable, immediate impact will be felt at the critical patient areas where increased staffing would be required to provide manual ventilation of intubated patients 7. Among the 33 assessed hospitals, only 30 7 Richard Aghababian, et al, Disasters within hospitals, Annals of Emergency medicine, 1994, 23:4 17

21 hospitals have an alternative power source, i.e. a generator. And among these 30 hospitals, only 11 reported that their emergency generator has the capacity to meet priority hospitals demand. The situation is extremely negative in Quang Ngai province where only one hospital satisfies this criterion. According to the WHO, hospitals generator(s) should be safely located in the premises not adjacent to the operating and ward areas 8. This is implemented by most of the hospitals. It can be seen from table 12 that as many as 27 hospitals reported that they have generator housing protected from natural and manmade disasters. Although generators are available in 30 hospitals, only 18 of them have automatic transfer switch. No automatic transfer switch may affect the continuity of hospitals operations due to interruption of power provision. Grounding of electric devices is of great importance to safety of users as well as the continuity of power supply. However, this importance seems to be underestimated by the hospitals. Only 13/32 hospitals reported that ground fault circuit interrupters are provided in outlets in bath and shower rooms and in wet or damp locations, only 12/31 hospitals reported that convenience outlets are provided with grounding pole, and only 13/33 hospitals reported that metallic parts of the electrical system that do not conduct current are adequately grounded. It is noteworthy that only 11/32 hospitals reported having exit lights luminous with battery backup. There is a gap between the real situation and the recommendation of they WHO which states that lighting should be available at all exits, including exit signs, stairways and corridors, especially in case of emergencies as accidents can occur if these areas are not properly lit and battery backup should be available for use during the period of transfer switching (the period between the interruption of power supply and the connection to a generator set). Results of further indicators used to assess the electric system are presented in table 13. Table 13. Electrical system Indicators Quang Ngai Phu Yen Bac Lieu Total Emergency generator has the capacity to meet priority hospital demands Generator housing protected from natural and manmade disasters Generator and other vibrating equipment can be fixed by special brackets that allow movement but prevent them from 1/10 No 6/12 No 4/8 No 11/30 0/3 9/10 Yes 11/12 Yes 7/8 Yes 27/30 3/3 6/10 No 10/12 Yes 7/8 Yes 23/30 2/3 8 WHO, Field manual for capacity assessment of health facilities in responding to emergencies, 2006, WHO 18

22 Indicators Quang Ngai Phu Yen Bac Lieu Total overturning Has non vibrating and silent generators; exhaust system should be made of critical type silencer or hospital grade and unit provided with vibration isolators if generator is in the hospital building Generator with automatic transfer switch Use of inflammable cooling system for transformer Use of bio-protection system certified standard wire, preferably with thermoplastic high heatresistant nylon insulation and cables securely fastened and tightly terminated on CBs or wiring devices Protected control panel, enclosed circuit breakers, magnetic contractors or fused or non-fused switches Ground fault circuit interrupters provided in outlets in bath and shower rooms and in wet or damp locations Convenience outlets provided with grounding pole Metallic parts of the electrical system that do not conduct current are adequately grounded, including electrical enclosures, boxes, gutters, ducts and trays Protected control panel, circuit breaker switch and cable follow the National standards and are 2/10 No 6/8 Yes 6/8 Yes 14/26 2/3 3/10 Yes 9/12 Yes 6/8 Yes 18/30 3/3 3/11 No 6/8 No 7/8 Yes 16/27 1/3 11/12 Yes 12/13 Yes 6/8 Yes 29/33 3/3 12/12 Yes 12/13 Yes 7/8 Yes 31/33 3/3 2/12 No 7/13 Yes 4/7 Yes 13/32 2/3 1/12 Yes 9/12 Yes 2/7 No 12/31 2/3 3/12 Yes 8/13 Yes 4/8 No 13/33 2/3 12/12 Yes 13/13 Yes 6/8 Yes 31/33 3/3 19

23 Indicators Quang Ngai Phu Yen Bac Lieu Total protected by an electrical surge suppressor All electrical systems and rooms protected with appropriate chemical automatic fire suppression units Ducting system-pvc for power and lighting, rigid steel conduit or intermediate metal conduit for fire alarm and detection systems; PVC for telephone, intercom etc Use of energy saving compact fluorescent lighting and mercury bulbs without mercury Adequate lighting in all areas of the hospital, including the grounds Exterior electrical system installed underground Functional electrical and emergency lights with battery backup in all critical areas Exit lights luminous with battery backup Backup power system can ensure 50-60% extra demand 2/12 No 2/11 Yes 2/8 No 6/31 1/3 11/12 Yes 12/13 Yes 6/8 Yes 29/33 3/3 8/12 No 12/13 Yes 2/8 No 22/33 1/3 10/12 Yes 13/13 Yes 7/8 Yes 30/33 3/3 6/12 No 5/13 Yes 4/8 No 15/33 1/3 5/12 No 11/13 Yes 5/8 Yes 21/33 2/3 1/12 No 7/13 Yes 3/7 Yes 11/32 2/3 1/12 No 9/12 Yes 4/8 No 14/32 1/ Communications system Communication is vital to the success of all coordinator efforts. Unfortunately, communication difficulties arising from both equipment failure and human error are the most common problems experienced during disaster situation 9. Data reveal positive results with 27/33 hospitals reporting having antenna and lightning rod protection terminals with bracing and support for safety. Also, as mobile phones are very common in Vietnam now, all hospitals reported this as their backup communication system. Moreover, as many as 25/33 9 Joseph F. Waeckerle, Disaster planning and response, New England Journal of Medicine, 234,

24 hospitals reported that their communication equipment and cables are secured with anchors and braces. However, weaknesses related to the safety of the communication system were also observed. Only 5 hospitals reported that exterior communication systems are installed underground. Specially, only one among 29 hospitals having fire alarm system reported that their alarm system can automatically transmit alarm to the nearest fire station or to such other outside assistance. This figure again confirms hospitals vulnerability to fire-related disasters. Detailed data for each province regarding hospitals preparedness in terms of communication system are presented in table 14. Table 14. Communication system Indicators Quang Ngai Phu Yen Bac Lieu Total Antennas and lightning rod protection terminals with bracing and support for safety Radios have backup direct current power source (battery) Presence of backup communication system Communication equipment and cables secured with anchors and braces Alarm system that automatically transmits alarm to the nearest fire station or to such other outside assistance as may be available Exterior communication systems installed underground Water supply system 10/12 Yes 11/13 Yes 6/8 Yes 27/33 3/3 0/4 No 3/4 Yes 3/8 Yes 6/16 2/3 2/2 Yes 5/5 Yes 8/8 Yes 33/33 3/3 11/12 Yes 9/13 Yes 5/8 Yes 25/33 3/3 0/10 No 0/13 No 0/6 Yes 1/29 1/3 2/12 Yes 3/13 Yes 0/8 No 5/33 2/3 It is stated by the WHO that water in a health facility should be safe and potable and contribute to the well being of patients by reducing risk of infection and propagation of food and water-borne diseases. 10. Only about half of the hospitals reported having water tank storage with sufficient reserve to satisfy the hospital demand for three days at all times. These include the provincial general hospital in Quang Ngai. However, two thirds of the 10 WHO, District health facilities, p

25 hospitals (22/33) reported that they have alternate water source, all being deep well, which positively reflects preparedness level of hospitals in responding to emergencies. Positive results are also observed with other water system-related indicators, which are presented in table 15. Table 15. Water supply system Indicators Quang Ngai Phu Yen Bac Lieu Total Water tank storage has sufficient reserve to satisfy the hospital demand for three days at all times Water storage tank has safe installation and location Alternate water source provided (e.g. deep well, local water utility, mobile water storage tank or fire truck) Water distribution system (valves, pipes, connections are free from leaks and harmful agents Wet standpipe shall deliver not less than 132l of water per minute for 30 minutes Technical rooms (operation theatre, laboratory, labour room, etc.) have quality water sterilization system Medical gas system 5/12 No 9/13 Yes 3/7 Yes 17/32 2/3 11/12 Yes 13/13 Yes 6/7 Yes 30/32 3/3 7/12 Yes 10/13 Yes 5/8 Yes 22/33 3/3 7/12 Yes 11/13 Yes 6/8 Yes 24/33 3/3 6/9 Yes 9/12 Yes 3/5 Yes 18/26 3/3 6/12 Yes 5/13 Yes 7/8 Yes 18/33 3/3 Medical gas supply is vital to the survival of some patients in the health facility but it is also a source of danger if not properly maintained. It should be noted that only about half of the assessed hospitals have central gas system (though in the emergency area only). Indicators used to assess safety of the medical gas system include those related to storage and anchorage of tanks, pipes, and safety of valves, which are presented in table 16. Among the sixteen indicators used, only four indicators are met by less than one third of the hospitals reporting availability of the equipment. However, these four indicators are of great importance to safety of the hospitals and their occupants. They are Medical gas pipes embedded in walls are provided with pipe sleeves (met by 10 over 17 hospitals), Anchors provided for tanks, cylinders and related equipment (met by 18 over 31), Industrial gases located outside the building and provided with automatic shut-off device (met by 2 over 24 hospitals) and All construction activity involving hazardous operations shall have not less 22

26 than one hour of fire resistance and all opening between any buildings and rooms or enclosures for hazardous operations shall be protected with self-closing or automatic fire doors (met by 6 over 32 hospitals). It can be seen that indicators used to assess the safety of the gas system here are merely related with the equipment. However, human related factor such as users capacity to operate and maintain the system is also essential to the safety of the system but has not been addressed. Table 16. Medical gas system Indicators Quang Ngai Phu Yen Bac Lieu Total Medical gas properly stored and secured in wellventilated areas or compartmented storage areas Safe and appropriate location for storage of medical gases and secured from theft and vandalism For hospitals using individual cylinders, minimum storage of three days Tanks bear an intact safety seal from the supplier Medical gas pipes embedded in walls are provided with pipe sleeves Anchors provided for tanks, cylinders and related equipment Safety of medical gas distribution system (valves, pipes, connections) ensured Functional pressure gauge and fittings Use of standard pipes (fireproof, waterproof) No interchangeable piping connection Undergoes regular testing procedures 10/12 Yes 11/13 Yes 5/7 Yes 26/32 3/3 4/6 Yes 11/12 Yes 4/7 Yes 19/25 3/3 9/12 No 10/13 No 8/8 Yes 27/33 1/3 11/12 No 13/13 Yes 8/8 Yes 32/33 2/3 1/6 Yes 5/5 Yes 4/6 Yes 10/17 3/3 5/12 Yes 7/12 No 6/7 Yes 18/31 2/3 2/6 Yes 9/10 No 6/7 Yes 17/23 2/3 11/12 Yes 13/13 Yes 7/8 Yes 31/33 3/3 3/6 Yes 11/11 Yes 4/5 Yes 18/22 3/3 2/6 Yes 5/8 Yes 4/6 Yes 11/20 3/3 8/12 Yes 12/13 Yes 7/8 Yes 27/33 3/3 With zone shut-off valves 1/6 Yes 9/10 Yes 4/6 Yes 14/22 3/3 23

27 Indicators Quang Ngai Phu Yen Bac Lieu Total in case of leaks Available backup oxygen tanks in case of emergency patient evacuation Industrial gases located outside the building and provided with automatic shut-off device Where activities or storage likely to involve an explosion hazard, explosion venting to outside the building shall be provided by thin glass or other approved vents All construction activity involving hazardous operations shall have not less than one hour of fire resistance and all opening between any buildings and rooms or enclosures for hazardous operations shall be protected with selfclosing or automatic fire doors 12/12 Yes 13/13 Yes 8/8 Yes 33/33 3/3 1/12 No 1/7 No 0/6 No 2/24 0/3 0/12 No 6/12 No 5/8 Yes 11/32 1/3 0/12 No 2/12 No 4/8 Yes 6/32 1/ Fire suppression system Fire is the most common hazard of every hospital therefore a fire suppression system is essential in every hospital s preparedness strategy for emergencies. According to the WHO, swift reaction in fighting fires depends on early fire detection. This can be achieved by installing smoke detectors fire alarm equipment at proper intervals to cover the entire building and. Also, equipment for local fire control such as fire hoses and fire extinguishers should be placed properly at high risk areas 11. Among the 33 assessed hospitals, only 26 hospitals reported availability of a fire alarm system. Among these only 6 hospitals, 3 of which are provincial level hospitals, reported that in their hospital, alarm, detection and extinguishing systems have interconnected automatic fire alarm system and automatic fire suppression system. Also, only six out 27 hospitals have a fire alarm system that can be a combination of automatic and manual. Also as few as 6 out of 27 hospitals reported that their fire alarm system is monitored by fire station or accredited monitoring agency. Similarly, very few hospitals (7/29) reported that they have heat and smoke detectors installed in corridors 11 WHO, Manual for capacity assessment of health facilities in responding to emergencies, 2006, WHO. 24

28 of hospitals, nursing homes and residential-custodial care facilities. Although hospitals reported availability of smoke detectors (29 hospitals), the number of detectors is not enough to cover all the buildings. Only 9 hospitals reported that smoke detectors are not spaced father apart than nine meters on center and more than four six tenths from any wall. As already mentioned, availability of fire extinguishers is a must to every hospitals to respond to fire-related emergencies. Although it is required that each room is provided with portable fire extinguishers, only 15/33 hospitals meet this criteria. Other indicators related to safety of fire suppression agents and operation of a fire safety program, which focuses on training for hospital staff, were observed with positive results as seen in table 17. However, it should be noted that these trainings are passive, conducted by the local fire management office. Therefore quality and effectiveness of training are other issues that also need to be assessed in the future. Table 17. Fire suppression system Indicators Quang Ngai Phu Yen Bac Lieu Total Alarm, detection and extinguishing systems have interconnected automatic fire alarm system and automatic fire suppression system Fire alarm system can be a combination of automatic and manual Fire alarm system is monitored by fire station or accredited monitoring agency Heat and smoke detection installed in corridors of hospitals, nursing homes and residential-custodial care facilities Smoke detectors must not be spaced father apart than nine meters on centre and more than four six tenths from any wall Use of extinguishing agents that are environment friendly, effective and cause less damage to property Each room provided with portable fire extinguishers 2/12 Yes 1/7 Yes 3/8 Yes 6/27 2/3 1/12 Yes 1/7 Yes 4/8 Yes 6/27 3/3 2/12 No 1/7 Yes 3/8 Yes 6/27 2/3 2/12 Yes 1/9 Yes 4/8 Yes 7/29 3/3 4/12 Yes 1/9 Yes 3/8 Yes 8/29 3/3 12/12 Yes 13/13 Yes 5/7 Yes 30/32 3/3 8/12 Yes 0/13 No 7/8 Yes 15/33 2/3 25

29 Indicators Quang Ngai Phu Yen Bac Lieu Total Recommended fire extinguishers: for electronic and electrical equipment, use carbon dioxide; for general services areas, use ABC fire extinguishers With wet standpipe system with complete accessories Has fire safety program with following features An organized fire brigade that has undergone seminar training on fire drills, fire evacuation drills, earthquake drills Conduct regular fire drills and fire evacuation drills (at least once a year) Conduct fire mitigation, prevention and suppression training Required firefighting equipment available Preventive maintenance of firefighting equipment Available fire exit plan and provision of fire exit evacuation plan in conspicuous places at every floor level 10/12 Yes 13/13 Yes 7/8 Yes 30/33 3/3 9/12 Yes 9/11 Yes 4/7 Yes 22/30 3/3 12/12 Yes 11/12 Yes 6/7 Yes 29/31 3/3 9/12 No 13/13 Yes 8/8 Yes 30/33 2/3 4/12 Yes 7/13 Yes 6/8 Yes 17/33 3/3 8/12 Yes 12/13 Yes 7/8 Yes 27/33 3/3 9/12 Yes 12/13 Yes 8/8 Yes 29/33 3/3 7/12 Yes 12/13 No 6/7 Yes 25/32 2/ Emergency exit system It is a must that hospitals are equipped with visible signs indicating location of escape routes and escape routes must have adequate lighting 12. This should be provided so that even a stranger unfamiliar with the hospitals surroundings can identify where he/she should go in case there is a need for evacuations. Absence of the signs and lighting may lead to confusion and panic during an emergency. This may subsequently give rise to occurrence of 12 PAHO, Mitigation of Disasters, volume 2, p

30 stampedes and/or trapping of individuals in enclosed spaces 13. Table 18 shows that only 20 hospitals reported that lighting is available in all exit points during emergencies and 19 hospitals reported that emergency lighting facilities maintain the specified degree of illumination in the event of failure of the normal lighting for a period of at least one hour. This result is consistent with the fact that very few hospitals (11/30) have emergency generator that has the capacity to meet priority hospital demands as presented in table 13. The situation of exit signs is also negative Twenty-six hospitals reported having exit signs but only 8 among these hospitals have illuminated signs, distinctive in colours and with reliable source. Only 8/18 hospitals meet the criterion of sign size and only 7/26 hospitals has luminous directional exit signs. It should be noted that all three provincial general hospitals meet all indicators of emergency exit system. Table 18. Emergency exit system Indicators Quang Ngai Phu Yen Bac Lieu Total Lighting available in all exit points during emergencies Emergency lighting facilities maintain the specified degree of illumination in the event of failure of the normal lighting for a period of at least one hour Illuminated EXIT signs distinctive in colour, reliable source Size of signs plainly legible letters not less than 15cm high with the principal strokes or letter not less than 19 mm wide Has luminous directional exit signs 5/12 Yes 12/13 Yes 3/8 Yes 20/33 3/3 6/12 Yes 10/13 Yes 3/8 Yes 19/33 3/3 1/12 Yes 4/8 Yes 3/6 Yes 8/26 3/3 1/12 Yes 4/8 Yes 3/6 Yes 8/18 3/3 1/12 Yes 3/8 Yes 3/3 Yes 7/26 3/ Heating, ventilation and air conditioning (HVAC) systems in critical areas Heating, ventilation, air conditioning (HVAC) systems help maintain indoor air temperature and humidity at comfortable levels. Moreover, HVAC systems control odours, remove contaminated air, and facilitate air-handling requirements to protect from airborne pathogens, thereby minimizing risks of microbial transmission from infected patients 14. Also, the HVAC system (e.g. hot water equipment) poses threat to safety of users while 13 WHO, Field manual for capacity assessment of health facilities in responding to emergencies, 2006, WHO. 14 LM Sehulster, et al, Guidelines for Environmental Infection Control in Health-care Facilities. Recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC0, (Chicago IL, American Society for Healthcare engineering/american Hospital Association) 2003, p.13 27