Disasters Within Hospitals

DISASTER MANAGEMENT MANAGEMENT DISASTER

Disasters Within Hospitals Disasters From the Departments Departments of From Emergency Medicine* Medicine' and Medicine, Medicine, ~t Emergency University Massachusetts University of Massachusetts Medical Center, Center, Worcester. Medical Worcester. Received for publication Received December 9, 1993. Accepted for December 1993. Accepted publication December December 21, 1993. publication

Richard Aghababian, Aghababian. MD, MD. FACEP* FACEP* Richard CPhuli Lewis. MD* MO* C Phuli Lewis, Gans. MD, MD. FACEP* FACEP* Lucille Gans, Curley, MD MOtt Frederick JJ Curley,

Hospital disaster planning planning should encompass events that affect affect Hospital hospital environment and address those meathe safety of the hospital availability of necessary services. sures that ensure the availability Although most of the emphasis emphasis has been placed on general disaster planning, planning. there is little little written written about disasters disasters occurring occurring within within aa hospital. hospital. In recent years, several incidents incidents at our mediinvolving fire, fire. flood, flood. and power failure resulted resulted in aa cal center involving reevaluation reevaluation of our preparedness preparedness to handle such situations. situations. These experiences experiences prompted prompted this discussion discussion and literature review of internal internal disaster planning. planning. Every Every hospital hospital should have acomprehensive a comprehensive internal internal disaster plan because it is likely that at some time an internal internal emergency emergency may occur. [Aghababian [Aghababian R. R, Lewis CP. CP, Gans Gans L L, Curley FJ: FJ: Disasters within within hospitals. April 1994;23:771-777.] hospitals. Ann Emerg EmergMed April 1994;23:771-777.]

INTRODUCTION INTRODUCTION In the United States, the Joint Commission on Accreditation Accreditation of Healthcare Organizations requires that all hospitals for both internal and external disasters. Because have plans for no specific guidelines exist for the design of hospital disaster plans, there is much variation in the quality, content, and detail of individual plans. 11 Most hospital plans concern themselves with "external" events, dealing specifically specifically with the management of a large from an emergency emergency that has volume of patients arriving from occurred outside of the hospital and has not had a direct hospital's service service capabilities. capabilities. 22-5 impact on the hospital's - 5 The term "internal disaster" refers refers to an incident that disrupts the everyday, everyday, routine services services of the medical facility facility itself. It mayor may or may not be associated with an external or communitywide nitywide event. event. Unless a hospital has experienced experienced an internal accident accident or support system system failure, failure, it may not have a detailed detailed internal disaster plan. The result of such an incident may require a myriad of responses, responses, such as evacuation evacuation of patients and myriad staff, staff, changes changes in the the levels levels of service, rerouting rerouting of hospital

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ambulance and and pedestrian pedestrian traffic, traffic, or or relocation relocation of of patient patient ambulance care areas, areas, defined defined by by an an internal internal disaster disaster plan. plan. care A series series of of internal internal disasters disasters at at the the University University of of A Massachusetts prompted prompted an an extensive extensive revision revision of of the the Massachusetts existing hospital hospital disaster disaster plan. plan. Review of of the literature literature in in existing that specifically addressed addressed this area revealed few articles that this the subject of internal internal disasters. disasters. Most discussions have the been concerned with hospital disasters that that coincide coincide with with been concerned with hospital disasters 10 6 external disasters. 6-1° the causes and and implicaimplica· external We discuss the internal disaster and and the design of a plan plan to tions of an internal and routinely drilled drilled and and updated updated by each be established and institution to minimize minimize functional disturbance disturbance in the event institution limited to those internal disaster. disaster. This discussion is limited of an internal situations in which the hospital is structurally intact. situations which structurally intact. internal fire, interruptions interruptions of water In recent years, internal and power failures failures with concomitant concomitant failure failure in the supply, and generator system have occurred at our facility. facility. backup generator inconvenient and and potentially Due in part to these inconvenient and cohesive hazardous occurrences, a more detailed and internal disaster plan has been developed. internal UNIVERSITY OF MASSACHUSETTS MEDICAL UNIVERSITY OF CENTER CENTER EXPERIENCE EXPERIENCE The University of Massachusetts Medical Center (UMMC) is a tertiary care medical faCility facility located in central Massachusetts, with a catchment population of approximately 1,000,000. 1,000,000. The center has three eight-story buildings-the ings--the medical school, science/research center, and hospital-that hospital--that are interconnected by several corridors above and below the ground. The medical center employs 6,000 people and educates about 600 individuals per year. Because the hospital serves as a major trauma center for for central Massachusetts, many of its 363 beds are used for for intensive care purposes and hence are vulnerable to power failures. Thirty percent of the beds have monitoring capability, and at any time as many as 15% may be occupied by patients requiring ventilatory support. Internal Internal Fire FireOn December 3,1984, 3, 1984, a fire fire occurred in the student laboratory area on the seventh floor floor of the medical school. This area has fire-resistant construction consisting of masonry block walls, reinforced concrete ceilings and floors, floors, and corridor doors of nonrated wood filled filled with with gypsum gypsum opening opening onto onto three three wings. wings. The The room room was was used used primarily primarily for for CPR CPR training. training. Stored Stored resuscitation resuscitation manikins manikins and and photocopier photocopier fluid fluid were were the the prinCipal principal fuels fuels for for aa fire fire that that resulted resulted from from aa short short circuit circuit in in an an electric electric power power strip. strip. Because Because there there were were no no smoke smoke detectors detectors or or sprinklers sprinklers in in the the room, room, the the fire fire was was not not detected detected until until smoke smoke from from the the room room entered entered an an exhaust exhaust fan, fan, triggering triggering aa

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smoke smoke alarm alarm in in the the hallway hallway at at 8:15 8: IS PM. PM. One One minute minute later, later, alarms alarms were were triggered triggered simultaneously simultaneously in in the the medical medical school department. Police Police and and school and and the the municipal municipal fire department. security security personnel personnel found found the the corridors corridors heavily heavily charged charged with with smoke, and and evacuation evacuation of the the sixth sixth and and seventh seventh floors was carried general carried out out at 8:20 8:20 PM, followed by a general evacuation evacuation of the the medical medical school at 8:30 8:30 PM. PM. During During the the firefighting fire fighting activities, activities, smoke smoke drifted drifted into into the the hospital hospital through through doors doors left open open to allow for hose hose lines lines and and movement movement of personnel. personnel. The nursing nursing supervisor made made the decision to move two ventilator-dependent ventilator-dependent and and six ICU patients patients on on the seventh seventh floor of the hospital hospital to the recovery area of the operating operating room on the third third floor. Three fighters received minor Three fire firefighters minor injuries, injuries, and and three employees were treated for smoke inhalation. inhalation. The seventh floor ICUs were reopened at 10:35 PM. Water Supply Supply Problems Problems UMMC has experienced water supply problems requiring requiring activation of the medical ceninternal disaster plan. ter's internal In May 1987, as a result of a rupture rupture in a city water line as it entered the campus, drastic changes occurred in the medical center's water pressure. Initially, measures were taken to restore pressure by preventing preventing unnecessary water usage; for example, 30% of the toilet facilities were closed and locked. Four hours later, it was established that water critical level. In addition, conpressure had dropped to a critical possibility that contamination contamination of cern developed over the pOSSibility water sources might have occurred; hence, the hospital's internal disaster plan was implemented. Outpatient clinics and elective surgery were cancelled; the hospital was closed to admissions, including trauma and air ambulance services; visitors were turned away; and those patients capable of being discharged were sent home. center's central vacuum suction system is The medical centers water pressure dependent. Because the system became from a nearby inoperable, an air compressor was borrowed from hospital to provide emergency suction capability. More than 200 gallons of potable water were delivered to the medical to provide a reliable but limited water source source for for center to food preparation, among handwashing, cleaning, and food received 6 gallons, and other needs. Each patient care area received food service service department received received 100 100 gallons. the food 16 hours after the internal disaster was Approximately 16 declared, pressure pressure and and water water supply supply were were completely completely declared, re-established and and the the disaster disaster was was declared declared over. over. re-established Power Failure Failure At At 9:02 9:02 AM AMon on November November 20, 20, 1992, 1992, the the Power entire medical medical center center and and medical medical school school complex complex experiexperientire enced aa power power outage outage due due to to aa failure failure of of all all external external enced power sources sources and and the the campus campus emergency emergency generator. generator. power Normally, the the hospital hospital power power plant plant isis fed fed by by three three electric electric Normally,

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feeder feeder cables with backup from an emergency emergency generator that is kept on line 24 hours a day day. A second generator can be brought on line if the need arises. city's electrical station resulted A power grid failure at the dtys in the loss of power from all three feeder feeder cables. Under normal conditions, the emergency emergency generator would supply the hospital's hospital's needs but, because of a subsequent relay failure from the generator to the hospital, the medical center's generator attempted to supply the city's power needs, resulting in an overload and shutdown with consequent total loss of power in the medical center. emergency generator Power plant personnel started the emergency manually and had emergency emergency auxiliary power restored in seven minutes; all power was restored in 19 minutes. Fortunately, no catastrophes occurred but much was learned that led to major changes in the internal disaster plan. The failure failure of critical care equipment would have been the most likely contributing cause of a catastrophic event. Normally, in the event of power failure, emergency emergency generator supply would commence and power supply to equipment such as ventilators would have been interrupted by 30 to 45 seconds at most. Without generator power, ventilators in the ICUs failed failed because these models had no individual battery backup. All ventilated patients required a minimum of 2: 2:1I staffing because of the need for manual ventilation and vital sign monitoring. Fortunately, this event occurred during daytime hours with ample staff. No units had more ventilator-dependent patients than available staff, as only 40 of the available 54 ventilators were in use. In the largest leU, ICU, 11 of the 12 beds were occupied by patients who had been recently extubated and were relatively relatively stable at the time of the power failure. All other monitored patients required I: 1:11 staffing for adequate manual monitoring. The heart-lung machines used for bypass surgery were supplied by independent battery backup power sources and operated without problem; thus, the two patients undergoing bypass were not significantly affected. affected. All other patients undergoing surgery were manually ventilated and monitored without complication. Communication is frequently frequently a major problem in disasters, and this event was no exception. The public address system was powered by the generator and was not well integrated into the overhead systems in other areas of the medical center. Thus, no overhead communication was possible initially Once auxiliary power was available the system was insufficient, because the command post was unable to hear public address announcements announcements as were the medical school and many other areas in the hospital (eg, stairwells, laboratories, laboratories, and restrooms). Lack of communication was

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a major contributor to anxiety anxiety and panic because persons trapped in elevators, darkened stairwells, and isolated rooms had no idea of the nature of the situation. situation. Lack of lighting in many areas was particularly hazardous. Initially, all areas were in total darkness. Fortunately, some daylight was present in areas with windows. Confusion would have been worse had the situation occurred at night. AUXiliary-powered Auxiliary-powered lighting, available in some areas, was on in seven minutes. Areas without auxiliary power, such as stairwells; arrested elevators; operating room corridors; many regions in the medical school; and windowless departments such as radiology, laboratory, and outpatient; corridors; and some sections of the emergency emergency department were without lighting for 19 minutes. Concrete stairways lacked reflecreflective lighting on stair ledges, creating a disorienting and potentially hazardous situation. There also was no legible means to distinguish floor level. In an elevator that housed 12 trapped persons, a cigarette lighter used for lighting could have proved fatal had flammable flammable gases been present. Most departments, particularly critical areas, flashlights. In addition, not lacked adequate numbers of flashlights. all crash carts had battery lights. Traffic/congestion Traffic/congestion was a major problem in several areas of the hospital. As darkness prevented a normal flow flow of formed at the main lobby and at other traffic, large crowds formed

Figure Figure 1.

Causes of intemal internal disasters External External Natural Earthquake Earthquake Tornado Tornado Hurricane Flood Flood Storm Fire Fire Manmade Terrorism Transportation Chemical/radiation Internal Internal Power Power failure Flood Flood Water loss loss Chemical Chemical accident/fumes Radiation Radiation accident FirefexpIosi 0 n/fumes Fire/explosion/fumes Loss Loss of medical gases gases Violence/bomb threat or explosion Inability of staff to reach reach hospital Loss Loss of telecommunications Elevator Elevator emergencies emergencies

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ports of entry such as the ED, creating an atmosphere of confusion and impeding emergency care. Greater numbers of security officers positioned at entrances to both direct and calm crowds would have been helpful. Staff members unaware of the cause of the power failure were anxious, as were patients, particularly those who had been monitored or were prepared for surgery. Although patient care was maintained successfully in all cases, one patient subsequently left the admitting area and refused admission for an elective surgical procedure. Patients, visitors, and employees trapped in elevators and dark stairwells admitted to feelings of distress and anxiety both dUring during and after the event. DISCUSSION

The hospital setting is rich in flammable and toxic materials, making it a potentially hazardous environment. The ever-increasing eve>increasing use of lasers amidst flammable gases in operating rooms,3 rooms, 3 storage of toxic substances, and routine use of radiation make most medical centers fertile ground for a catastrophic event. This fact, coupled with the reliance of advanced medical care on electrical power, creates a vulnerable environment.1 - 13 The causes of an environment. ~11-~3 internal disaster are multifaceted, as shown (Figure 1). External causes, natural or manmade, may affect the hospital directly or indirectly and will involve both internal and external disaster planning. An effective disaster Figure 2.

Survey for internal disaster disaster plan

Name/Department

_

Emergency Emergency power: Emergency Emergency power is provided by the power plant to critical life support areas of the hospital. Emergency Emergency lighting is provided throughout the hospital and most other areas. Are there pieces of equipment or areas within your area area that are not on emergency power that you feel should be? be? Please Please list them.

If your area area had to only use emergency power for more than 24 hours, would you be able to continue critical function? Loss Loss of water: If your area area had acomplete a complete loss of water for two hours, would you be able to function? What would the consequences be? be? What if the loss less of water continued for more than 24 hours? hours? Destruction Destruction of area by by firelflood: fire/flood: If your area area and most of its equipment were destroyed by fire or flood, or were inaccessible for use due to toxic area be relocated to another area area of campus? campus? Do you fumes, could your area have have a e plan to protect, salvage, or relocate relocate critical equipment in the event of a a disaster? Are there any other issues regarding your area area in adisaster a disaster that you would like to make the committee aware of?

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plan cannot be created unless each cause is considered separately. As demonstrated by these events, unexpected incidents can suddenly affect the smooth functioning of a hospital, highlighting the need to create, drill, and implement an internal disaster plan. An internal disaster plan is multiinvolving coordination of all hospital faceted, involVing departments, which should be represented in the disaster planning process. Prior to updating our disaster plan, a survey of each department (Figure 2) was conducted to determine both needs and vulnerability. An internal disaster plan should be able to work in conjunction with pre-existing external disaster plans and should address the features outlined in Figure 3 and discussed below. Defining what would constitute an internal disaster in one's facility is imperative. At UMMC, any event that threatens the smooth functioning of the hospital, medical school, or research center, or that presents a potential danger to patients and/or hospital personnel is considered an internal disaster. Our disaster plan is divided into three response phases. Phase 1 is an alert phase, during which staff remain at their regular duties and wait for further instructions from their supervisors. Phase 2 is a response phase, and deSignated designated staff report to supervisors or the command post for instructions. Phase 3 is the expanded response phase during which additional personnel are reqUired. required. Therefore, off-duty staff are called in to the hospital, and existing staff may be relocated within the medical center. The internal disaster plan should address the institution's response to an incident that disrupts hospital function, with the external disaster plan deSCribing describing the management of the injured. After any emergency, it is imperative that the structural integrity of the hospital be evaluated to determine whether continued, albeit limited, medical services are safe. A command post must be predetermined. A specific location must be designated, including an alternative site in the event of structural instability or other problem at the predesignated site. This site should have emergency power capability. The staffing (core stafD staff) of this post must be outlined clearly to avoid confusion. The core staff is responsible for making all major decisions regarding the assessment and response to an internal disaster. Our facility uses a core staff of only three individuals (the hospital director, chief of staff, and senior nursing coordinator in house). In addition, there is an adjunct staff of four, one each from the engineering (physical plant), public safety, admitting, and secretarial departments.

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representative serves serves as In our institution, the nursing representative for most internal disasters. the command post leader for However, under certain circumstances circumstances the core staff may However, leader. For choose to designate another individual as the leader. instance, the head of the physical plant may take on this engineering failure. The adjunct role in the event of an engineering staff serve serve in an advisory advisory capacity and would be in constaff communication with other members of the disaster stant communication team. The command post responsibilities are outlined in Figure 4. As occurs in an external disaster response, the most senior physician in the ED would retain primary for triage and management of people responsibility for injured dUring during the disaster. It is important that all potenfamiliar with the tial core and adjunct staff members be familiar disaster plan and be properly trained to fulfill their particular duties. Resources available to the command post should Resources flashlights/battery-powered include cellular phone(s), flashlightslbattery-powered lamps, radios (walkie-talkies), blueprint-style plans of the building indicating location of major services, and telephone numbers for all departments, pay phones, elevators, regional contacts such as ambulance/transport companies, National Guard, police, civil defense, Red Cross, and media. Specialized or essential areas of the hospital (eg, operating room, ED, pharmacy, radiology, laboratoFigure 3.

Features of internal internal disaster plan Definition Command Command post Location Location Staffing Responsibilities Responsibilities and powers Individual plans External External disasters: disasters: natural/manmade natural/manmade Fire Fire Flood/loss Flood/loss of water Loss Loss of power Loss Loss of medical medical gases gases Elevator Elevator emergencies emergencies Loss Loss of compressed compressed air/vacuum Inability of personnel personnel to reach reach hospital Toxic exposures: exposures: radiation, radiation. chemical, chemical, fumes Loss Loss of telecommunications telecommunications Terrorism/violence/bomb Terrorism/violence/bomb threat Evacuation procedures Plans for unique areas Building layout/maps Appendix Regional Regional contacts Sources Sources of water, oxygen, oxygen, pharmaceutical pharmaceutical supplies Essential Essential phone phone numbers numbers (departments, (departments, elevators, public phones, phones, key personnel, personnel, media) medial

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ries, blood bank, power plant, and food food services) services) should have a floor floor plan in which battery-supplied backup equipment, emergency emergency supplies, and electric electric and water lines are clearly marked. clearly The hospital disaster plan must anticipate and address external external disasters such as hurricanes, hurricanes, tornados, earthquakes, or explosions that directly directly affect the medical center. center. Such events events are are most challenging challenging because, in addition to creating creating chaos within a faCility, facility, there may be increased numbers of patients, problems for for additional staff reaching the faCility, facility, and increased stress on the staff present due to fears and uncertainties regarding their own homes and family family members. During California's Loma Lama Prieta earthquake experience,2 experience,2 communication communication with family family was a major problem for for most staff members. In designing a plan, it is necessary necessary to consider laboratory equipment failure; potential chemical spills; and losses of radiography capability, suction, communication, lighting, medical gases; and structural stability. It is important to establish who will assess structural stability under varying conditions (eg, fire, earthquake, explosion) and clear guidelines for such an assessment are essential. essential. Fire plans should include a general plan such as closure of windows and doors as well as a clear announcement declaring that the disaster phase is in effect effect and whether evacuation is necessary. In general, a disaster plan would not be implemented initially unless fire spread beyond a single closed room. Occasionally, an internal fire is associated with loss of power. Although often contained within a small area of a hospital, the spread of noxious fumes may affect large areas in a short time, as occurred at UMMC. frequently will be followed by loss of water Flooding frequently pressure and vacuum because suction devices are driven by water pressure in most facilities. In addition there may be an inability to run water-cooled instruments (eg, lasers), loss of sanitation, malfunction of many laboratory lasers), machines, an inability to develop x-ray films, and an increased risk of fire. System planners must be aware of available reserve water in the form of tank water (there is available Figure 4. ResponSibilities and powers of of aa command post Responsibilities Suspend or reduce reduce hospital services services Suspend Order evacuation/relocation Order Coordinate manpower pool Coordinate Request outside assistance assistance Request Coordinate all communications communications Coordinate resumption of suspended suspended services services Order resumption

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a 40,OOO-gallon 40,000-gallon reserve at UMMC). General stores of potable water also should be secured for emergency emergency supply. To determine minimum water supply reqUirements, ply. requirements, one must consider sprinklers, sterilization, x-ray film film developing, toilets, toilets, sinks, and kitchen needs for the entire hospital. Loss of power is only a disaster when the auxiliary power sources fail to meet needs. This is unusual but must be considered, as even the most advanced systems may have a relay problem or general failure. The immediate impact is on critical patient areas requiring increased staffing to provide manual ventilation of intubated patients and vital assessments of monitored patients. Battery-operated ECG and emergency emergency pacing and defibrillator units must be available at predetermined locations. Adequate numbers of flashlights flashlights should be housed in readily accessible locations in critical patient care areas, as well as elevators and stairwells, stairwells, and on crash carts. Reflective stripping should be applied to steps to prevent falls. falls. Communication is essential to quell fears and prevent panic, particularly for persons trapped in elevators. elevators. Adequate numbers of security personnel must report to areas of congestion to prevent the general public from entering the facility facility and to clear hallways to ensure that patient care, particularly in critical areas, is not hampered. Loss of medical gases would be devastating to oxygen-dependent patients. Because most ventilators require sufficient outlet pressures to function, all intubated patients would need to be ventilated manually with portable oxygen tanks. One must ascertain how long backup supplies could support a facility. facility. At UMMC, complete failure of oxygen systems lasting more than one hour would require transfer of lCU ICU patients unless further oxygen supply could be secured. In addition, patients undergoing surgery could not receive volatile anesthetic gases. Elevator emergencies emergencies rarely require declaration of a disaster but typically occur during loss of power, fire, or flood. All elevators should have telephone communication. communication. If possible, elevators should have auxiliary lighting, or the telephone should be illuminated. Nonfunctional elevators should be checked by telephone operators systematically systematically to monitor trapped individuals, reduce fear, and provide updates for those trapped. An elevator emergency is particularly difficult during an evacuation situation and must be considered when designing evacuation plans. Loss of compressed air and vacuum will occur in most cases if there is a loss of water or power. Compressed air is used to power mechanical ventilators, and loss of

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compressed air will result in a ventilator switching to t o an internal compressor. Some high-frequency high-frequency ventilators (often pediatric) lack internal compressors, and manual ventilation may be required. Lack of vacuum for bedside suction is rarely an emergency emergency situation, and portable easily. units, though less efficient, may be substituted easily. Personnel may be unable to reach the hospital after a natural disaster such as storm, earthquake, flood, or hurricane. The immediate impact should be minimal as existing personnel may be used but could become problematic if large numbers of patients arrive as a result of a coexistent external disaster or if the disruption persists more than several days. Alternative methods of staff transportation using local police, fire fire departments, or the National Guard should be identified in advance. In addition, child care for employees with children should be considered as schools and daycare facilities may be affected. affected. Toxic exposures involving fumes, fumes, radiation, or chemical accidents within the hospital will normally be managed in conjunction with local fire and facility facility management personnel. Hazardous materials information and material safety data sheets should be accessible to guide response. Loss of telecommunications telecommunications may be partial or complete. Most facilities maintain a battery backup for public address and paging systems. In the event of prolonged service disruption, personnel may have to use pay phones; a list of locations and numbers should be readily available within the disaster plan. Cellular phones also may be useful for external communications. Violence, terrorism, or bomb threats may endanger the safety of personnel and patients. In most cases, it is the responsibility of security officers to coordinate response with the police and fire departments. The command center then would assist in coordinating any necessary evacuations. Evacuation may be classified as either horizontal or vertical. A horizontal evacuation involves moving patients single dangerous area, usually on the same away from a Single floor. Vertical evacuations involve movement of persons to other floors or outside. Evacuation routes for personnel and patients should be predetermined to prevent congestion and undue confusion. 14,15 ~4,]5 Potential relocation areas for all essential departments should be established in advance, using resources such as army reserve buildings, school shelters, National Guard headquarters, or other neighboring hospitals. On notification of patient evacuation, medical and nursing personnel should triage and classify all patients prior to moving them. Color or numerical classification classification

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systems used in other disaster settings can be used. In most cases, patients with life-threatening life-threatening illnesses, illnesses, necessitating ventilator support or close monitoring, would be designated as critical. Such patients would be given first priority for immediate transport. Nonambulatory, moderately unstable patients such as those recently admitted or recently recently postoperative, would be triaged as second priority and should be moved next. Stable, ambulatory patients would be triaged as low priority, and their transfer could occur using fewer fewer staff.

10. Henry S: Assoc J S: Mississauga Hospital: Largest evacuation in Canada's history history. Can CanMed MedAssoc 1980;122:582-586. 1980;122: 582-586. 11. Sankaram K, K, Roles A, Kasian G: G: Fire in an intensive care unit: Causes and strategies for prevention. Can Assac J ;145:313-315 CanMed Med Assoc J 1991 1991;145:313-315. 12. The devastation of patient fires. Health HealthDevices Devices1992;213-29. 1992;21:3+29,

13. Farman JV: Fire risks risks in in intensive care units and operating theatres. Proc ProcRSoc R Sec Med Med 1976;69:603-604 1976;69:603 604. 14. Department of Veteran Affairs: Emergency EmergencyPreparedness PreparednessPlanning PlanningGuide GuideBook Book.St Louis, MO, 1992, P p 114:1-6 11:4:1-6. 15. Auf der ACEP tier Heide E:E: Community Community hospital and medical medical disaster planning guidelines. ACEP Handbook. Handbook.Disaster DisasterPreparedness, Preparedness,1993. 16. Baughman 1990;16241-242. Baughman K: K: Internal Internal disaster drill critique. J Emerg EmergNurs Nurs1990;16:241-242. 17. Nagel E, E, Perdue M, Hayes J, et al: Drill DriPI prepares OR OR for fire emergency emergency. Hospitals Hospitals 1973;4799 1973;47:99

CONCLUSION CONCLUSION

18. Cruickshank Australas Nurs Cruickshank KJ: KJ: Fire and evacuation planning in hospitals hospitals. Australas NursJJ 1978;17-14. 1978;1:7-14.

The Joint Commission on Accreditation of Healthcare Organizations requires that all hospitals in the United States have external and internal disaster plans because of the great potential for catastrophic loss of life and injury to staff. staff. Because little has been published about the incidence and types of internal disasters, planning based on experience is that much more difficult. Perhaps hospitals are reluctant to divulge information regarding internal emergencies emergencies as it may be perceived as a weakness, but it is inevitable that external events will damage hospitals, accifire or toxic spills will occur, and natural dents such as fire wear and tear will cause power lines and plumbing to give way from time to time. Internal disaster plans should be integrated into every hospital disaster preparedness protocol. The types of internal disasters reviewed reviewed should be included as well as other potential problems specific to the hospital or its locale. Training for external and internal disaster should be mandatory for all employees. employees. Drills should be designed and routinely performed to ensure that staff are adequately prepared, t6-~s prepared 16 - 1H Hospitals should be encouraged to share their experiences and provide safety equipment to support the staff in the event of an internal disaster.

no. 47/1/54408 47/1154408 Reprint no. Address for reprints: reprints: CPhuli C Phuli Lewis, Lewis, MD MD Department Department of Emergency Emergency Medicine Medicine University University of Massachusetts Massachusetts Medical Medical Center Center 55 Lake Avenue Avenue North North Worcester, Worcester, Massachusetts Massachusetts 01655 01655 508-856-1707 508-856-1707 Fax 508-856-6902 508-856-6902

REFERENCES REFERENCES 1. 1 Kai T. T, Pretto E:E: Hospital preparedness in Osaka, Japan Japan. Prehosp PrehospDisas DisasMed Med 1993;8:S91. 1993;8:$91. 2. Ricci E, ;7471E, Pretto E E: Assessment of prehospital and hospital in disaster disaster. Crit CritCare CareClin Clin1991 1991;7:471487 3. Aghababian R: R: Hospital disaster planning. planning. Topics TopicsEmerg EmergMed Med 1986;746-53. 1986;7:46-53.

EnglJ Med Med 1991 1991 ;324:815·821. ;324:815-821. 4. Waeckerle JJ: Disaster planning and response. N Engl 5 J Accid Surg 5. Rowlands B B: Are we ready for the next disaster? Br BrJAccid Surg1990;2161-62. 1990;21:61-62. 6. 8, Haynes BE. BE, Freeman C. C, Rubin JJ: Medical response to catastrophic events: California's planning and the Loma Prieta earthquake Ann Emerg earthquake, Ann EmergMed Med 1992;21368-374. 1992;21:368-374.

M: L'hfJpital L'h6pital en situation de catastrophe catastrophe Cahiers CahiersdAnesthesio/l d'Anesthesio11988;36:631-640. 7. Cara M 988;36:631-640. 8 02. 8. Friedman E E: Updating disaster plans: AA tale of three hospitals hospitals. Hospitals Hospitals1978;52:95-1 1978;52:95-102. 9 J Med1972;116639. Koegler Koegier R. R, Hicks S S: Destruction of a a medical medical center by earthquake. West WestJ Med1972;116:63+ 66.

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