responding to a fire at a pediatric hospital

APRIL 2002. VOL 75, NO 4 Hogan

Responding to a Fire at a Pediatric Hospital

isaster preparedness programs established in located in downtown Toronto and covers approximate- health care organizations are an essential ele- ly 2.5 million sq ft, which is one complete city block. ment in facilitating a formalized, effective The hospital includes a level three nursery and a response to major incidents or disasters. One pediatric trauma emergency room, has multiorgan D author states that there are two categories of transplantation designation, and supports all medical

disasters-natural and man made.’ Natural disasters and surgical pediatric services. The hospital averages are caused by extreme environmental conditions that 50,000 emergency visits, 275,000 outpatient visits, give rise to catastrophic destruction and death. Man- and 17,000 surgical procedures per year. made disasters are caused by human action or inaction and can have profound effects on civilians, govern- HSC‘S DISASTER RESPONSE PLAN ments, and economic stability. This article reviews Disaster response focuses on victim care.’ In a one man-made disaster-a hospital fire at the Hospital hospital disaster, each patient must be accounted for for Sick Children (HSC), Toronto. along with any family members or friends visiting

when disaster occurs. All staff members in the build- THE HOSPITAL ing need to be identified and accounted for to prevent

The hospital comprises three main structures- casualties at the disaster site. the annex building, atrium, and research center. The As part of HSC’s disaster plan, the emergency annex building was constructed in 195 1, and the atri- management team has established direct lines of con- um was built and connected to the trol, defined the duties of person- annex in 1993. The research center nel with an assigned role, defined is a separate building connected to A B S T R A C T procedures and responsibilities for the atrium by a second floor pedes- Disaster preparedness in health care providers and engi- trian walkway. All buildings at health care organizations facili- neering and plant staff members, HSC have the most current fire tates a formalized response to and determined equipment and systems available. These systems major incidents or disasters. This supply needs for each response use heat, smoke, and fire sensors; article reviews a man-made dis- hnction. They also have planned sprinkler systems; smoke evacua- aster, a fire at a large pediatric an emergency measures coordination windows; extraction fans; fire hospital. HOW the fire started, tion center, which would be a com- extinguishers; and fire barrier patient evacuation, redirecting mand post for managing resources, doors. The annex and atrium build- services, timing of events, key analyzing information, and mak- ings were designed so that tire can- players, geographic factors, ing decisions during a disaster. not spread through them quickly communications, and recovery The plan calls for the emer- and so that, in the event of a fire, and restoration of care are dis- gency management team to people can be evacuated quickly. cussed. Lessons learned and assume responsibility and control

The hospital is a tertiary information on disaster pre- for incident-related activities. One teaching hospital and the largest paredness also are presented. individual on the team should children’s hospital in Canada, with AORN J 75 (April 2002) 793- assume the role of incident com- a 375 inpatient bed capacity. It is 800 mander and oversee the technical

C A T H E R I N E HOGAN, R N

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Staff members used disaster

manuals, workaround plans,

and backup supplies for Y2K

to care for evacuated patients.

aspects of the response. Staff members on each nursing unit should identify a person who will be responsible for maintaining direction and control at the unit level and interacting with the management team. Management team members determine short- and long-term effects of the disaster; interact with hospital staff members, family members, the media, and outside response organizations (eg, fire department, police department, ambulance service, Salvation Army); issue press releases; and order the evacuation or shut down of the hospital. Without a coordination center, adequate coordination fails and communication links are diminished within and among responding agencies involved in disaster contro1.j

Preparing for potential year 2000 (Y2K) prob- lems had increased the hospital’s readiness for a disaster. Preparation had taken more than one year, and it incorporated all areas of the hospital. Plans for each type of code were reviewed and refined, and “workaround plans” were created for scenarios, such as patient care without water or power. Extremely detailed plans for every unit and department were included in the disaster manuals, including disaster evacuation.

Hospital staff members participated in regularly scheduled fire instruction and monthly mock fire drills. As part of Y2K planning, medical supplies, equipment, and resources needed to treat patients had been increased for a possible Y2K disaster. These materials were stored in various locations throughout the hospital.

THE FIRE On Sunday, Jan 9,2000, at approximately 6 PM,

patients, parents, and staff members at HSC were fin- ishing the evening meal. Fire bells sounded in response to an explosion in a high voltage power

transformer in the hospital basement. The explosion destroyed the containment vault and ignited a fire that precipitated an evacuation. The mild weather on the night of the disaster facilitated a barrier-free, swift response by fire, ambulance, police, and volunteer responders.

The explosion and subsequent high-intensity fire shattered windows in the atrium building, crumbled the loading dock, and knocked out power inside the hospital and for a six-block radius surrounding the hospital. Emergency backup power was restored inside the hospital in a matter of seconds; however, the fire burned out of control for two hours. Regular power was restored to the hospital 22 hours after the explosion. Smoke and soot from the fire quickly infiltrated the annex and entered the nine-story patient wards of the atrium.

The hospital alert (ie, code red) was initiated throughout the hospital, and staff members began the practiced routine of accounting for patients, family members, and staff members and securing all doors. Protection services notified the administrative coordinator on duty that it was not a false alarm but a real fire in the annex. The child health services manager on call was notified, and staff members were contacted and given assignments. By 6: 15 PM across the city of Toronto, radio and television media were broad- casting stories about the fire at the hospital.

Potentially toxic smoke generated by the fire infiltrated the atrium, posing an immediate threat to patients, family members, and staff members and putting them at risk for hyper responsiveness to smoke particles. Inhalation injury from the presence of large quantities of smoke greatly increases the incidence of respiratory failure and acute respiratory distress syndr0me.j Fire smoke consists of various materials and particle matter, depending on the materials burning.’ As this was a hydroelectrical vault burning, it was assumed that some level of polychlo- rinated biphenyls were present, posing a threat to human health and life because man-made toxins were being released by the fire.

The south side of the building received the great- est amount of smoke. The neonatal intensive care unit (NICU), critical care unit (CCU), cardiac unit, and remaining floors on the south side of the atrium needed to be evacuated. Staff members used the disaster manuals, workaround plans, and backup supplies for Y2K to care for evacuated patients.

The emergency measures coordination center was established in the emergency department, and

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everyone focused on the horizontal evacuation of patients to the north side of the building. The center was supposed to be located in the annex; however, the fire was in that zone and the secondary location was in use. The evacuation bells (ie, code green) sounded, and the nursing coordinator notified all resource staff members, personnel in charge, and nursing staff members on the units on the north side of the hospital to prepare their areas to accept patients from the south side of the atrium. An effective response to the fire and evacuation required a comprehensive, coor- dinated, multidisciplinary approach.

Patient evacuation. The NICU had 29 patients. These patients needed to be moved quickly because immature airways of premature neonates may have surfactant deficiency in the lungs, which can lead to respiratory distress." Arrangements were made with Mt Sinai Hospital across the street, which has a level three nursery, to accept nine of the high-risk neonates. Normally, patients needing transfer to Mt Sinai would be transferred via an underground tunnel that con- nects the hospitals; however, the tunnel was filled with smoke, so patients had to be transferred above ground in very cold temperatures. Police officers and fire department personnel created a human corridor to facilitate the transfer. The patients, who were in incubators, were prepared for transfer and accompanied by two or three nurses, a respiratory therapist, and a physician to Mt Sinai's nursery. The remaining NICU patients were moved in their incubators upstairs to the north side of the fifth floor.

The CCU had 18 patients, 17 of whom who were evacuated to the postanesthesia care unit (PACU) on the north side, which had the necessary support systems and resources to provide advanced prolonged life support. The distance from the CCU to the PACU is approximately one city block; therefore, the transfer took approximately 20 minutes. Each patient was moved with all necessary support equipment and med- ications by nurses, physicians, and respiratory therapists, and there was no lapse in treatment. One patient who was connected to a special type of heart bypass machine could not be moved, and nurses, physicians, respiratory therapists, and fire personnel stayed in the CCU throughout the fire to support this patient. The PACU recently had admitted two postoperative patients. The other 14 patient cubicles and two isolation rooms were filled with evacuated CCU patients and medical personnel. The resource staff member in the CCU, along with members of the fire department, checked all rooms in the CCU to ensure no one was

left behind, reported to the coordination center, and returned to the PACU. Patients in the cardiac unit were moved across the building to north clinic rooms, which normally are used for day patient care.

In the PACU, one anesthesia care provider acted as the captain for disaster management. Medical run- ners from the anesthesia department were dispatched with the on-call anesthesia care provider from the PACU to each unit on the remaining six floors of the atrium to assess airway and medical status of patients. Patients, family members, and staff members on these floors were evacuated horizontally to the north side without incident. Any patients identified as being at risk were evacuated to the ORs. Emergency procedures were complete, and no procedures were pend- ing. This enabled staff members to prepare five ORs adjacent to the PACU to receive these evacuated patients.

Nine children were supported in five ORs. Oxygen and thermal regulation support were available, and anesthesia machines could be used to venti- late patients if needed. Two ORs housed three patients each, and three ORs housed individual pediatric patients needing isolation and minimal medical support. All nine patients were accompanied by a medical team from their original unit. Family members accompanying patients were greeted by a peri- operative nurse who provided emotional and environmental support during the disaster. When the threat to life and limb is critical, the normal OR environmental controls are suspended until the threat is diminished. The triage team in the PACU used all available space in the unit-the natural overflow space was the ORs. The ORs used were isolated in one wing directly across from the PACU, and access from the ORs to the central core was restricted to OR personnel only. Traffic to the room was conducted via the hallway linking the OR to the PACU. The ORs were chosen because of the cleaning standards, which ensures minimum microbial growth. Routine OR environmental controls (eg, standards for attire) were suspended. The rooms were cleaned terminally after the patients were returned to their wards.

Redirecting services. To establish direction and control. emergency department services needed to be relocated to satellite centers outside HSC. Multi- disciplinary teams from HSC established these services in adjacent acute care hospitals peripheral to the disaster zone but within the normal traffic routes to HSC (ie, Toronto General Hospital, Mt Sinai). Communication links were established with other

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downtown hospitals, and the ambulance services team redirected patient care activities to Mt Sinai, Toronto General, and St Michael’s Hospital.

It was determined that future surgical procedures would be performed at Toronto General. Staff members and any supplies needed for procedures would be relocated to Toronto General. Supplies and instru- ments were prepared for transport to the satellite surgical site.

The diagnostic and support services most heavily affected by the explosion and fire included mag- netic resonance imaging (MRI), computed tomogra- phy (CT), interventional radiology, stores and receiving, pharmacy, and central processing. Staff members from the diagnostic imaging department established a satellite site at Toronto General for MRI, CT, and interventional procedures during the disaster.

TIMING OF M N T S The explosion and tire occurred at 6 PM.

Change of shift for hospital staff members occurs at 7:15 PM. Staff members coming on shift were en route to the hospital. Change ofshitt for tire, police, and ambulance services occurs at 7 PM. Traffic flow in Toronto was low during this time, which facilitated easy, quick access to the hospital for both hospital employees and emergency responders.

The annex building at HSC is used Monday through Friday for outpatient care and business activities. with the exception of CT, MRI, and interventional radiology, which are used for emergency care support on evenings and weekends. Very few people were in the annex at the time of the explosion because of its limited weekend use. Overall, hospital census was low at 225 patients because of the Christmas slowdown and Y2K preparedness.

KEY PLAYERS The activation phase of disaster response

includes assessing the scene initially and ensuring mobility of resources. The first responders on-site should perfonn a scene assessment, estimate the extent and type of disaster, survey the extent ofenvi- ronmental damage, and identify which routes to the disaster site remain accessible.’

Key internal players during this disaster included protection service employees, who reported the actual fire to the administrative coordinator; the information worker at the communication switchboard, who directed and maintained telephone and overhead communication links; and the emergency response

team, whose team members were responsible for establishing the emergency measures coordination center. All staff members on duty were critical internal players at the disaster site.

Key external players during this disaster included the more than 100 firefighters who responded to the fire scene with 23 fire trucks; every available police officer in Toronto; and ambulance service employees. The hospital also was overwhelmed by off-duty staff members from all services who returned to HSC to assist in any way they could to ensure the safety of patients and staff members.

GEOGRAPHIC FACTORS The Hospital for Sick Children is located in the

downtown core of Canada’s largest city. It is situated strategically between two larger adult teaching hospitals, Mt Sinai and Toronto General. Within six city blocks are two additional adult acute care hospital centers, one of which is St Michael’s, an emergency trauma center. All potential trauma patients 16 years of age and older could be redirected to Toronto General or St Michael’s. All patients younger than 16 years of age could be redirected to the satellite pediatric emergency sites established at Mt Sinai and Toronto General.

The Toronto fire department has several downtown stations fully equipped to handle high-rise fires. The evening the fire occurred, public and private transportation networks that provide access to downtown were free of obstacles (eg, snow), and there was little traffic because it was Sunday. Multiple traffic arteries lead to the downtown area. The subway system has several stops within a one-block radius ofthe hospital. All of these factors facilitated quick pathways for disaster responders.

COMMUNICATIONS Success or failure of disaster response is deter-

mined greatly by access to communication and reliable information.Y Success requires appropriate means to collect, process, and transmit critical information efficiently in the midst of disaster. Emergency communication systems need to be set up to establish contact within the disaster zone and with the outside world, warn personnel of the danger, keep family members and off-duty employees informed, and coordinate response actions.”

The hospital switchboard was operated by one information worker, and incoming telephone calls overloaded the telephone lines and overwhelmed the

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information worker after the media broadcast reports of the fire. As a result, the emergency management team used contingency plans for total communication failure. Protection services and information services established backup communication systems and relayed the system to the coordination center. Extra personnel were dispatched to the switchboard, and nonessential telephone calls were rerouted to voice mail boxes.

The backup communication system used messen- gers, telephones, portable radios, cellular telephones, point-to-point private lines, and satellite communication systems. Regular telephones were the primary link between the units. The emergency management team used portable walkie-talkies for roving reports from within the hospital to the coordination center.

Communication with other hospitals and external agencies occurred via land lines and cellular telephones, which use satellite communication systems. The HSC media representative relayed information about the disaster to the media teams, who used satellite broadcasts to notify the public. Keeping all communication links open during the implementation phase of disaster response reflects the dynamic nature of a disaster zone. Constant assessment, monitoring, and reconfiguration of the plan was necessary.

COMMUNITY OUTREACH The disaster at HSC precipitated an immediate

community response because children’s lives were at risk. Fire, police, ambulance, and emergency support services personnel were the first community responders. After reaching the scene, the fire chief activated the Toronto emergency services disaster plan.

The chief met with staff members in the coordination center to discuss options and life safety. If smoke continued to fill the hospital, a complete evacuation would be needed. One option remained. The hospital is equipped with smoke evacuation windows and extraction fans. With the fire still burning, the atrium windows could be opened and the extraction fans turned on. The fear, however, was that this would draw the fire through the annex into the atrium, causing a greater threat to patients and necessi- tating immediate evacuation.

All wards were placed on standby for a complete hospital evacuation. The smoke windows on each unit were opened, and the fans were turned on. The fans sounded like a helicopter landing in the atrium, but the effect was instantaneous. The smoke was being pulled out. The fire chief and protection serv-

ices reported that there was no movement of the fire, and in 30 minutes the smoke level diminished in the atrium patient units.

The Toronto ambulance service used the provin- cial communication system to redirect potential incoming patients from outside the greater Toronto area to alternate facilities in the province. Members of the emergency management team established communication links with all hospitals in greater Toronto to facilitate preparedness of alternate care sites and potential evacuation sites to support HSC patients if an evacuation was deemed necessary. Ambulances with pediatric patients were redirected to satellite emergency sites. The ambulance service also provided emergency services transportation buses, which were parked outside HSC. In the event of a complete hospital evacuation, these buses would provide critical transportation support.

Off-site support sites were established. One site was established to provide support for parents and family members who were not in the hospital when the fire started. The second site was a rest and nourishment area for emergency responders. Both sites were established and maintained by community support groups. A third site was established for media. The media ofi- cer in the coordination center maintained regular communication from the disaster site to the media site and other support sites. Members of the media are the most important link between a disaster site and the public because they can be used to create a positive witness environment. Keeping the public up to date can deter members of the community from coming to the disaster site and compounding the danger to others in the disaster zone. The police erected a barrier line around the hospital to control access, and members of the media were prohibited from crossing the barrier.

RECOVERY AND RESTORATION OF CARE Recovery and restoration go right to the heart of

HSC’s mission-to provide the best in family-cen- tered, compassionate care. By 11 :30 PM on January 9, the fire was out, patients had been returned to their original units, and restoration of care was established. A hospital-wide check for damage was underway. Areas heavily damaged by smoke and soot included stores and receiving, which supplied products for the hospital; central services, which supplied sterile products, instrumentation for surgical services, and other products for the hospital; diagnostic imaging; CT; interventional radiology; and pharmacy.

Communication to vendors about replenishing

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supplies and stock began immediately. Vendors, responding to the media coverage, contacted HSC departments and offered essential assistance to bring hospital systems back up. The insurance adjuster was on-site by midnight gathering data, giving directions regarding what to do with damaged products, and supplying fire cleanup support from companies spe- cializing in fire site restoration. Cleanup had begun, and arrangements were made to have outside help in restoring the stores and receiving, central supply, and pharmacy departments.

The diagnostic imaging department, when viewed by emergency lighting, did not appear to have been damaged; however, in the light of day, every- thing was covered with soot. No supplies could be washed, so they were bagged, tagged, and stored for the insurance adjuster. All OR supplies for 8 AM procedures were in case carts in the OR when the fire started; however, supplies in central services had to be unwrapped, washed, rewrapped, sterilized, and stored in another clean area to prevent cross contam- ination from the soot in the department.

The management team became the recovery team. Recovery team members contacted key members of every department and reviewed which hospital activities would resume and which would be canceled for Monday. A floor-to-floor nursing unit and department-to-department assessment by the recovery team established the structural and operational impact of the fire damage and the timelines and actions needed to return to normal business. All clinics and ofices in the annex were closed Monday to check for damage and allow for cleanup. The media played a key role in informing the community regarding the cancellation and rescheduling of appointments. A telephone number that contained a prepared statement regarding the fire and the hospital’s return to normal activity was set up for family members to call.

Off-duty clinic staff members were notified to assemble in the garden patio cafeteria at 7 AM Monday. A centralized scheduling site was set up in this area so patients could reschedule canceled appointments. Hospital staff members manned all entrances to the building and directed families that arrived for clinic visits to the patio. Children and family members who had traveled a distance from within the province were seen to prevent undo hardship on the child and family.

Employee support was vital. Staff members were provided critical incident stress debriefings to communicate the events of the fire and information

about the recovery and restoration process. These sessions were held at various times in a central location, and employee assistance counselors went to each unit to talk with staff members, patients, and family members.

Every effort was made to protect undamaged property; however, with the amount of soot in the building, this became difficult. Maintaining complete and accurate records of damaged goods and supplies to ensure an efficient recovery program was a chal- lenge because each item needed to be recorded. Keeping records also was necessary in the event the insurance company needed them to facilitate an accurate settlement or future legal action.

LESSONS LEARNED Emergency communication during the disaster

was hampered by the use of portable radios because not all staff members were familiar with their use. Management team members used portable radios that were not on the same frequency as the police, fire, and ambulance responders. They have since attended incident management systems training from Toronto emergency services and, in the future, will be able to access the secure portable radio frequency for disaster communications and reliable information. Hospi- tal staff members act as consultants and work in col- laboration with regional and national vendors in the delivery of care products for patient services. Fostering strong partnerships with vendors before the disaster resulted in their help replacing supplies to continue patient care delivery.

Transport of patients from HSC to alternate care sites was not needed; however, it was discovered that the emergency services transportation buses were not appropriate for incubator support. Alternate resources are being sought to address the needs of neonates. Evacuated patients were received on the north side units; however, supplies were needed beyond the stock on these units. Staff members returned to evacuated units when supplies were depleted. In the future, the carts with patient care stock items and medication carts will be transferred to the evacuation site with the units’ patients.

The patient rooms in the atrium are single-occu- pancy rooms. Two patients were put in one room on the receiving unit; however, the rooms have only one oxygen and suction outlet. The supply of oxygen cylinders and regulators has been increased to support more than one patient in a single room should the need arise.

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The emergency measures disaster plan has been revised to include new fan out phone sheets (ie, algo- rithm charts that reflect a set of rules and procedures that must be followed in solving a problem or situa- tion) for each unit, clinic, and division in HSC. To coordinate and use all available resources effectively, HSC has given management team members formalized training that establishes common terminology and modular organization of roles; integrates communication pathways; and unifies a command struc- ture with fire, police, and ambulance responders.

One of the most challenging and compounding factors in the disaster zone was the overwhelming number of volunteer responders. The hospital has multiple points by which staff members and medical responders entered the building and took the shortest route to their assigned unit. A command post was set up in the atrium lobby, and responders entering there were checked, recorded as being on-site, and deployed to a specific unit. General public responders also managed to gain access to the building and were redirected outside the building beyond the police line. Family members who were at home when the fire started and later arrived at the hospital were taken by a staff volunteer to the family support site. Plans are being established to secure all entry points into the hospital to decrease the risk of injury to others.

DISASTER PREPAREDNESS A disaster preparedness plan should establish a

written emergency measures plan, maintain training programs and records, document drills and exercises, and critique programs and drills for revision, if needed. Designate the site of the emergency coordination center, publish the site in the disaster manual, establish emergency training at different levels for mem-

NOTES 1. N S Oster, “Disaster medi-

cine,” The Mount Sinai Journal of Medicine 64 (September/October 1997) 323-328.

2. Ibid 3. V Garshnek, F M Burkle, Jr,

“Telecommunications systems in supporting of disaster medicine: Applications of basic information pathways,” AnnaIs of Emeeenq Medicine 35 (August 1999) 213-218.

bers of different response teams, and establish agree- ments with other hospitals in the event alternate care sites or evacuation are needed.

During a major incident or disaster, establish telephone logs, document details of the events, maintain records of injuries and follow-up actions, account for personnel, coordinate notification of family members, issue press releases, and document incident investiga- tions and recovery operations. Have one member of the logistics team arrange for medical support, transportation fiom the site, and shelter sites for responders, family members, and the media. Two other team members should be assigned to provide backup power and establish alternate communication systems.

CONCLUSION Fear of fire is rooted so deeply that many people

panic when they hear the call “fire” or the sound of a fire alarm. In their own terror, they may overreact or underreact.’O Disaster planning and preparedness can limit the extent and scope of human casualties, dimin- ishing the threat to life in a disaster.”

Any type of major incident or disaster, whether it be natural or man-made, can be devastating. Having a disaster preparedness plan, however, can help alleviate some of the devastation. If a plan is in place when a disaster occurs and staff members are familiar with it, hospitals can lessen the amount of harm caused. Disaster preparedness plans bring order to chaos and help make disasters easier to deal with for all involved. A

Catherine Hogan, RN, MSN, is the child health services director of the patient operative care unit, the Hospital for Sick Children, Toronto.

4. T L Lee-Chiong, Jr, “Smoke inhalation injury,’’ Postgraduate Medicine 105 (February 1999) 55-62

5. Ibid. 6. Ibid. 7. Oster, “Disaster medicine,”

8. Garshnek, Burkle, Jr, “Telecommunications systems in supporting of disaster medicine: Applications of basic information pathways,” 213-218.

323-328.

9. Ibid 10. Oster, “Disaster medicine,”

1 1. M Wolraich et al, “How pedia- tricians can respond to the psychoso- cia1 implications of disasters: American Academy of Pediatrics. Committee on psychosocial aspects of child and family health, 1998- 1999,” Pediatrics 103 (February

323-328.

1999) 521-523.

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