Joplin Tornado & Northeast Disasters: The Assessment & Lessons for Tomorrow

Transcription

1 Joplin Tornado & Northeast Disasters: The Assessment & Lessons for Tomorrow Presented by: Scott Aronson, MS Principal Russell Phillips & Associates, LLC Offices in CA / CT / NY / OH / RI Who is Russell Phillips & Associates? Since 1976 Fire, Emergency Management & Life Safety Code/SOC Compliance Exclusively for Healthcare 1,300 Healthcare Clients US & Canada (representing more than 2,200 healthcare facilities) New England: More than 75 hospitals and 480 LTC facilities Reviewers of Local/National Disasters 9/11, Tropical Storm Allison (Houston), Katrina, CA Wildfires, Multiple Patient Fatalities in Fires, Joplin Tornado, Hurricane Irene, Halloween Snowstorm, etc. National Committees Advisors on The Joint Commission Committee for Healthcare Safety NFPA Healthcare Executive Board Vice Chair NFPA Healthcare Emergency Mgmt. Technical Committee NFPA 101 Voting Member 1

2 Recent Disaster Incidents (On-site Assessments) Tornados in Tuscaloosa & Moulton, AL (4/27), Joplin, MO (5/22) and Springfield, MA (6/1) Earthquake in the Northeast US Hurricane/Tropic Storm Irene & Lee Flooding 7,000 patients/residents evacuated in NY alone CT hospital evacuation generator fire Wildfires All over Snowstorm/Power Failure New England Oct/Nov The Joplin Experience May 22, :41 PM (Evacuation / Surge) 2

3 Joplin Tornado Healthcare Delivery System: 2 Acute Care hospitals 756 licensed beds 389 beds (Freeman plus 32 SNF) 367 beds (St. John s) 187 patient on the day of tornado and ~25 in ED 6 Skilled Nursing Facilities 692 licensed beds Greenbriar 120 Meadows Care 120 Joplin Healthcare Center 86 Joplin Health & Rehab 120 NHC Joplin 126 Spring River Christian Village Kansas City Star Article, 6/20/11 The Emergency Department physicians on duty looks up and sees a security guard tearing down the corridor. Take cover! the guard shouts. We re gonna get hit! Wind roars with such force the steel beams supporting the hospital s top floors twist four inches. Glass explodes from every window; the air turns cold; lights flicker and die. The building jolts and is cloaked in blackness. Both generators, main and backup, have been blasted from their foundations. Water pipes burst, showering everything. Ceilings cave; wires hang in the air like spider webs and spill on the floor. Explosive natural gas spews from broken pipes on the lower floors. 3

4 Our Client Honoring Their Staff Tornado Impact That Evening Hospitals: 367 of 756 licensed beds gone St. John s Hospital: CLOSED Before: 9 story building with 367 licensed beds After: 3 tent field hospital with 60 beds, 20 for ER and 40 for patients April 15, 2012: Temporary Hospital (150k sq ft / prefabricated structure) Freeman: 389 beds 361 staff had homes destroyed out of 4,300 Nursing Homes: 326 of 692 licensed beds gone Greenbriar 120 (CLOSED 14 fatalities: 1 staff/13 residents) Meadows Care 120 (CLOSED) Joplin Healthcare Center 86 (CLOSED) Joplin Health & Rehab 120 NHC Joplin 126 Spring River Christian Village

5 Tornado vs. Earthquake Drop, Cover & Hold Move Patients into central corridors away from windows / doors to exterior If unable to do so (e.g. higher acuity): Move away from windows and cover with blankets / overbed tables If unable to do so: Cover patients with blankets By all means, don t stand in a door frame that has a door on it! Window Impact - February Dept. of Army Waterways Experiment - Equivalent to 1000lbs TNT at 275 feet distance 5

6 Hospital Impact St. John s Hospital Evacuation Fires and exposed electrical throughout Evacuation of all patients in 90 minutes (~187) Generator failure destroyed (roof units land on the power plant) Vertical evacuation completed in dark stairwells (NFPA 99 potential issue on lighting) LTC - Immediately Post Strike Moved patients away from flowing water (sprinklers) What is your shut-off valve strategy on Sunday evening? Gas odor strong on exterior of building Concerned about evacuating outside What is your procedure for HVAC shutdown / containment? Coordination of staff by Nursing Super and Charge Nurses no leadership for 1+ hour What was the Incident Command System used? Staff Calm Patients Calm 6

7 Key Components to a Full Building Evacuation (FBE) Plan Activation of Plan and Labor/Personnel Pool Establishment of Internal Holding Areas Patient Preparation on Units Marking of Patient Rooms (evacuated) Coordination of Transportation Determination of Receiving Sites Patient Tracking (internal and external) Joplin Evacuation Reality Emergent Situation Patient Preparation on Units Meds & Personal Belongings in bags / Charts on laps Marker with last name on arm Marking of Patient Rooms Checked over and over again (Door Tags Recommended) Immediate Threat Patient moved vertically all means employed Marking of Patient Rooms Checked over and over again 7

8 Joplin Evacuation Reality Emergent Situation Determination of Receiving Sites No coordinated support Coordination of Transportation (patients) Pick-up trucks and 4 door sedans All POVs destroyed at facility EMS on-scene 2 hours post event 1st ambulance transport at midnight due to disaster Immediate Threat Determination of Receiving Sites No coordinated support Coordination of Transportation (patients) Pick-up trucks, 4 door sedans and carried All POVs destroyed at facility Minimal EMS Capabilities in early phase due to community/infrastructure impact Joplin Evacuation Reality, cont d Emergent Situation Coordination of Transport. (equip) Pick-up trucks Mattresses, wheelchairs, meds (beds - next day) 30 minute cycle Immediate Threat Coordination of Transport. (equip) Pick-up trucks / Box Trucks Salvage Operation Patient Tracking Census Log - both ends No Patient Evacuation Tracking Forms used Patient Tracking None in initial window 8

9 Hospital Surge Freeman Medical Center Surge (41 ED treatments beds): 20 Minutes: 200 patients 120 criticals 90 Minutes: Hours: ~1,500 1,700 total treated Largest Single Influx of Patients in the US (on record) 389 Bed Hospital - Surge Process Standard Process (24 hour period) Discharges Additional Beds Surge to 480 Patients 9

10 Catastrophic Surge (Joplin) Catastrophic Surge Process Census Reduction (no time) Surge Equipment, Staff and Resources may or may not come Patients Process for Increasing Capacity Census Reduction / Rapid Discharge Open beds Utilize procedural/recovery areas as surge beds Expand patient room capacity Rule of Thumb 13 room depth expand to 2 nd bed at the wall, 3 beds, 3 between beds, 3 bed Factor: Bathroom door and level of care Vent or other special equipment; cribs or isolettes vs. beds 19 room depth expand to 3 rd bed 10

11 Surge Capacity Mass Casualty Incident (MCI) Operational Hospital Established 2 points of external triage Standard Team initially with PA/MD and Nurse at triage Jane / John Doe 1, 2, 3+ All charge nurses that were not delivering direct care moved to the ED Transportation: Walking / Carried / Car / Pickup (almost no ambulance traffic initially) 11

12 Operational Hospital MCI, cont d External Triages overwhelmed within 20 minutes, 3 additional areas established Jane / John Doe 1, 2, X-rays / 396 CT Procedures (18 hours) Clinical staff from St. John s and staff coming in 154 physicians / 883 staff arrived within 1 hour No power / no exterior lights (2 hrs. for portable lighting) EMS Ambulance stacked up to ¼ mile at 1 hour window Stabilize and transport directly on the ambulance MCI, cont d Internal Patient Placement 41 bed ED - PODs for types of injuries Ex: Yellow Pod Ortho ; Red Pod Cardiac / Chest 200 patient in ED and every slot stacked Main Lobby 300+ patients Expanded a clinical unit to open 35 beds Due to ICS issue, no one ever informed ED NO BEHAVIORAL / PATIENT / FAMILY ISSUE Eerie quiet 800 patients in hospital at one time 4 security & 12 maintenance no PD or Nat. Guard 12

13 Communications Satellite Phone Failed (projectile) Landlines Failed Cell Phones Failed (1 type worked from roof) Text Messaging Usually Worked Internet Failed 2-way Radios - Worked Runners Worked HAM Worked (once on-scene) Utilities Water (70lbs to 22lbs) Water Plant hit and limited to no water pressure All bottled drinking never an issue Toilets Force flush only / barrels placed on all floors Tankers brought in for fire protection and other utilities Fire department handled Usage requirements???? Dialysis Boil order in effect Decision made to use water from tankers Generators 13 hours on generators (community down 3-5 days) 3 rd feed comes into hospital that enabled Empire Electric to run new lines in the middle of night 13

14 The Joplin Experience May 22, 2011 October 4, 2012 Heroic People Committed to Community We Will Rebuild New: 825,000 sq ft hosp 261 beds (expand to 309) Mid 2015 The New England Storms of

15 June Tornadoes Hurricane/Tropical Storm Irene 15

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17 Regional Medical Coordinating Center/ Long Term Care Coordinating Center Operating in MA and CT (W. NY also) Function of Coordinating Centers Assist and coordinate patient placement Support patient tracking - Close the loop Assist with obtaining staff, supplies and equipment Assist with transportation of staff, supplies and equipment Interaction with local, regional and state agencies ENSURE EVERYONE IS ACCOUNTED FOR 17

18 Prioritization / Coordination Facilities Grouped for Tracking Group 1: Reported No Issues (no actions taken / not called) Group 2: Reported Issues (communicated with between 1-2 times daily for situation updates and resource needs) Group 3: Did Not Report Considered at risk until communicated with Drains resources when the facility is OK and did not report Actions in Irene and Halloween Storm Reporting: Online Emergency Reporting completed Situation Report: Provided 1-2 Times Daily to DPH and Regional Partners (submitted to CMS/HHS) At Risk : Members Communicated with CT: 21 out of 91 (Irene) / 62 (Alfred) / 118 bed vent hospital MA: 47 out of 447 (Irene) / 54 (Alfred) Activation: Full stand up on multiple occasions for potential or actual Evacuating Facility IRENE NOTE: In CT - 4 of 91 had generator failures at one time or another (4.4%) 18

19 One Hospital s Irene Experience Preparation: Command Center activated pre-assigned operational periods Tree clearing completed vulnerable areas Additional clinical, ancillary & support staff on duty Resources & Assets enhanced Top off fuel tanks Advance supply order received Hospital Size: 98 beds / 180 bed LTC on campus Irene: *43 inpatients and 5 ED patients * due to decompression ahead of storm August 28 Irene Strikes: 0820 Power Fails / Emergency Generator working 1527 Generator shorts and fails CT Hospital Evacuation 1527 Generator Fire: 750kw (suppressed with extinguisher) Commercial Power Down / No Elevators 1532 Unified Command established with Fire Dept Primary phone system fails 1600 Decision to Evacuate Evacuation commenced for ED patients (not admitted) 1615 Electronic patient tracking system in place 1643 EMS Strike Teams activated and DPH Licensure staff onsite 1905 Commercial power restored Evacuation Continues (CEO decision on hill/wind gusts) 2200 Last patient evacuated 19

20 CT Hospital Evacuation (cont d) Vertical Evacuation (EMS/Fire equipment): No elevators / 3 flights of stairs Stairchairs Backboards Scoop Stretchers Lighting Issues: Poor illumination from emergency lighting Could not see >30 into facility Fire Dept. supplemented stairwell lighting Pyxis Issues: Access issues CT Hospital Evacuation (cont d) Medical Records: Medical Records went with patient and a nurse sent to each receiving hospital Nurse copied medical records at Patient Accepting Facility 4 hours for first 33 patients and 2 hours for final 10 Issue: Had commercial power / Records copied on-site Holding Area: One point of discharge EMS coordinated regional tracking and transportation Hospital clinical handoff for Critical Care patients No clinical handoff or communications for Med/Surg Patient Families: All communicated to 20

21 CT Hospital Evacuation (cont d) Distribution: 7 hospitals / 3 LTC (not their own) Patient Tracking: EMTrack / EMS Log at exit Activation: Major Communications Issue Disaster Struck Facility: Full Activation Patient Accepting Facilities: Limited Activations Close the Loop: Hospital called everyone-status Mutual Aid Plan: Design commenced in December 2011 Go live date of May 17, 2012 to tabletop and FSE in Fall 2012 Major Success (hospital, EMS, RESF8, Fire): 3 C s Communication, Coordination, Cooperation Emergency Generators (failure) How deep have you gone? Service Patient Care Towers Service areas with High Acuity Patients Do they parallel each other for redundancy? Do you have a quick connection pre-wired with transfer switch? Voltage / Kw / Service Amperage Cable Run (in feet to the electrical service) Fuel Source Exact Location on Campus (trailer mounted) 21

22 Hospital Surge Halloween Storm 520 Bed Hospital: additional patients Excluding ED Boarders Conversions (sample): Closed Unit 25 bed patient care area Rehab Storage Unit 14 beds for shelter boarders Swing Unit 22 beds housing discharged patients Could not go home Day Care Activated 24/7: All staff Showers / Sleeping: Any staff who required it Electives: Cancelled in many areas 22

23 Hospital Decompression Frail Elderly / Medical Equipment / Clinical Needs 1. Standard Discharges No power at home 2. Medicare Eligible 3 day length of stay requirement (major hindrance for LTC) 3. Medicaid Eligible PASRR and Ascend Issue: Communication issue b/w hospital and LTC believing all of this was waived Solution: DPH Blast Fax and Notification 4. Private Insurance days / until can return home 5. Private Pay 3-5 days / until can return home Hospital / LTC rate discussions 23

24 Emergency Reporting System Information Key contact during event Beds Status and Type Operational Issues and Specifics Transportation Vehicles, Capacity & Deployment Time Staff, Numbers / Type and Deployment Time Resources & Assets you can provide Resources & Assets you may need 24

25 Successes 100% accountability for all regional facilities Tracked & effectively managed operational issues or needs: vendor / equipment / supply needs Communication Process with DPH, Coordinating Centers and ESF 8 Communication Process with Healthcare Facilities (no one stood alone) Surge Plan with DPH and Bed Reporting Updates Challenges Regional Shelters vs. Regional Medical Shelters Should the hospitals fully operate or locals? Age old question Emergency Credentialing & Sharing of Staff Decompression of hospitals 1135 Waiver would have minimized obstructions to decompress hospitals Communications between hospitals and LTC Hospital Evacuation: What is an emergency to one may be a normal day to another 25

26 National Issue: Consistency in Handling Disaster Events Single Facility Event / Isolated Incident Extremely challenging to preplan payer process Fire or other immediate threat emergency forcing evacuation Single Facility Event / Regional Impact State typically has exhausted all resources prior to waiver request Multiple Facility Event / Regional Impact Easiest to secure 1135 Waiver Scott Aronson, MS Principal Russell Phillips & Associates, LLC saronson@phillipsllc.com Offices in: California / Connecticut / New York / Ohio / Rhode Island 26