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DISASTER
RECOVERY
JOURNAL
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INTERNATIONAL
CONTACTS
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Business Continuity
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Journal of Business Continuity
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Quake Japan Co., Ltd.
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CASE STUDY
Flaming
Car In Lobby Tests Hospital Plans, Employees
By THOMAS J. HUSER, MS, CHSP
It is truly rare that a facility actually puts their disaster plans
into action. Most facilities have elaborate plans, which look good on
paper and are well executed during the semi-annual drills. Most facilities
do not have the opportunity to truly test their plans to see if the
paper plan works as well as they believe that it will. We had such an
incident at St. Vincent Hospital in Indianapolis and we discovered very
quickly that what looks good on paper does not always translate to a
good plan when placed into practice. This article covers the incident
which we experienced in hopes that others may learn from our mistakes.
Background
In the Spring of 1994 several members of our disaster committee attended
the annual National Disaster Medical System (NDMS) conference in Florida
where the primary topic was the response to Hurricane Andrew. With the
information fresh on the minds of the attendees, it was determined that
our current system of incident management was no longer appropriate
for the needs of a 1.5 million square-foot medical-surgical facility
licensed for 700 beds.
The co-chairs of the committee, Robert Lew, MD and Joanne Wilson, RN
decided that all of the plans needed to be scrapped and new plans based
upon the incident command system (ICS) needed to be created and put
into place. As a recent graduate of the National Fire Academy Incident
Command course, I was appointed to this sub-committee.
Through 1994 we worked to revise all of our disaster plans so that they
were modeled upon the ICS method of incident management. We removed
the CEO and the “administrator on-call” from the lead position
and replaced them with the “disaster coordinator.” Numerous
personnel were trained to fill this role to allow for a disaster coordinator
to be on site 24/7. There would be no need to wait for a return call
in order to implement a disaster plan. A command center was established
with the primary equipment being placed on a cart to allow for mobility.
A color-coded flow sheet was developed to act as a guide as well as
a record of actions taken during a disaster activation. Clipboards with
position descriptions, forms, and identification vests were also placed
on the cart. Soon training was begun for those who would be disaster
coordinators in the event of a disaster activation. A video was made
to allow for frequent review of the Disaster Command Center as well
as the flow sheet and the support roles. We had drills and made modifications.
We were ready, or so we thought.
The Incident
The date was July 30, 1999, which was to be recorded as the hottest
day in Indianapolis for that year. At 11:05 a.m. a gentleman drove his
auto through the main entrance of the facility into the main concourse.
He then turned right and drove the car approximately 50 feet where he
exited the vehicle, then returned to set the vehicle (which was doused
with gasoline) on fire. Within moments of the fire alarm activating
members of the security department, facilities and environmental services,
and the fire response team, were on the scene attempting to extinguish
the fire. The fire was controlled by one sprinkler head and personnel
from the concourse (see time line on the following page). Telecommunications
called the fire department to verify receipt of the alarm. Responding
fire units, believing the call to be a false alarm, failed to put on
their protective fire gear. The first arriving engine was to have established
radio contact with our security department. However their radio did
not work and initial radio contact was not made. As the fire department
arrived, they saw smoke emitting from the north end of the concourse
and reported a working fire. They also quickly discovered the fire hydrants
to which they connected had low water pressure.
Internal response was rapid as word quickly spread of the incident.
Personnel began to assist the injured. There were seven victims including
the driver. One of the responders was the disaster coordinator assigned
to that shift. She soon became involved in patient triage and treatment
and the disaster plan was never activated. Soon several personnel, none
of which had been trained as disaster coordinators, stepped into the
command void. They quickly began to issue conflicting orders to hospital
staff.
The fire system responded as it was designed, containing smoke to the
concourse and main lobby. It was soon discovered that as personnel were
entering the area, to assist or just to look, they were allowing the
smoke to migrate to other areas of the facility, causing more alarms
to activate. Rumors of evacuations soon began as personnel continued
to operate without a central command structure. I was notified of the
incident and returned to the facility as the post incident meeting of
senior leadership was being organized. After speaking with the fire
investigator and attending the meeting, it quickly became evident that
our “model plan” had failed and that a post-incident critique
would be necessary in order to sort through the events.
The Critique
The critique was conducted the following week and included the following:
From the Washington Township Fire Department were the on-duty battalion
chief, fire marshal and deputy chief. From the hospital were the vice
president of clinical and non-clinical support services, the director
of facility services, the manager of security services, the security
teamleader, director of emergency services (chair of the disaster committee),
the fire alarm technician, the director of nursing administration (the
on-duty disaster coordinator) and myself. The critique revealed that
several items went according to plan. However we also learned there
was a great deal of room for improvement. Following is a summary of
the post-incident critique.
What went right:
• The fire system activated appropriately and contained the smoke.
• The fire was contained by the activation of one sprinkler.
• Fire response team personnel responded with more than 14 fire
extinguishers.
• Personnel were evacuated from the immediate area and placed
in a central location for triage and transport.
Opportunities for Improvement:
• No one called telecommunications to notify them there was an
actual fire.
• The first notification of the alarm was made by the hospital
personnel, not the fire alarm monitoring company.
• There was no radio contact with the responding fire department
units.
• The disaster coordinator became involved in the incident and
failed to activate the disaster plan.
• Numerous unqualified personnel issued conflicting orders.
• Sightseers undermined the smoke barriers by continually opening
the fire doors.
• Unauthorized personnel entered the crime scene.
• Low fire hydrant water pressure.
• Inability to use the “Spectra-link” telephones outside
of the building and difficulties with the disaster radio system.
• The fire department did not receive confirmation that there
was an actual fire.
• Confusion as to responsibility to transport patients.
• No unified command was established for all responding agencies.
Post-Incident Changes Enacted:
• A training blitz took place to remind associates of the need
to contact telecommunications via the “code phone” to verify
the reason for the alarm. The education was accomplished via internal
print and virtual newsletters. The need was also reinforced as part
of the annual fire safety in-service.
• As a result of our experience with the alarm monitoring company
a formal proposal was made to the life safety committee requiring health
care facilities call their local fire department to verify receipt of
the alarm. This proposal has been accepted and is expected to be brought
to the full membership for approval at the upcoming NFPA meeting.
• The phrase “do you need to activate the disaster plan”
was added to all of the disaster plans. Since the incident began as
a fire, consideration for activation of the disaster plan was not given.
Educational sessions were conducted with all disaster coordinators to
reinforce the need to implement the disaster plan to establish a clear
line of authority during an incident.
• Educational sessions were held with all leadership personnel.
We recently had experienced a change in several senior leadership positions
and the new personnel were not familiar with their role in the event
of a disaster. They were informed that they are to assume a role supporting
the disaster coordinator who would have authority during a disaster
plan activation. This education now takes place on a regular basis as
leadership changes occur.
• Unauthorized personnel entering the area created two problems.
The first being the opening of the fire doors, which allowed the smoke
to enter portions of the building that should not have been affected
by the incident. The second being the potential contamination of the
crime scene by these persons. Security has modified their portion of
the disaster plan to include provisions for the placement of personnel
to restrict access to fire/crime scene areas.
• The local municipal water utility was contacted and asked to
raise the water pressure on the grid that effect the fire hydrants on
the eastside of the facility. The request was refused. They maintain
that the pressure is adequate for our needs and if needed in an emergency,
the pressure could be increased. The water company was just sold to
the city and another request has been filed. We are currently awaiting
their response.
• Personnel responding were utilizing Spectra-link telephones.
These phones are a cordless telephone system that operates in a manner
similar to cellular phones. These phones have a very limited range and
must be close to a “cell” to operate. To remedy the limited
range of the system, additional cells were established on strategic
light poles outside of the facility. This allows the telephones to operate
in areas external to the building. The radio system was also reviewed
and changes were made in the location of the radio antenna to allow
for a greater range of operation.
• The lack of information to the fire department and their responding
units was caused by failures at the hospital and at the fire department.
The failure of hospital personnel to contact telecommunications impeded
their ability to notify the fire department of the events taking place.
The fire department had hospital radios in the first responding units.
However the radios had not been maintained and communication did not
occur between the responders and security officers on the scene. New
radios were installed in the first and second due apparatus (engines,
aerials, rescue, and ambulances) and the battalion chief’s vehicle.
The radios were placed on a preventative maintenance schedule to ensure
they function appropriately.
• After much discussion it was decided that transport of patients
suffering from traumatic injuries is best accomplished by the fire department.
They have the training and equipment to move the patients in the manner
that prevents further injury.
• The lack of the unified command occurred for several reasons.
The failure of the hospital to activate our command system, the sheriff
and fire department’s failure to recognize the seriousness of
the situation and the resulting media attention (the day before this
incident there was a multiple shooting at a office tower in Atlanta,
Ga.). The fire and sheriff departments have changed their standard operating
guidelines to request the mobile command post for any incident involving
a multiple agency response.
Aftermath
As a result of this incident numerous changes have been made by the
hospital as well as by the responding agencies. All of the injured have
recovered fully and the driver of the vehicle was sentenced to 20 years
imprisonment for his actions. He is facing deportation upon his release
from prison.
I would recommend you take the time to take a hard look at your disaster
plans. Do not be afraid to work with someone familiar with disaster
planning and response from outside of your facility for an impartial
perspective. It is better to find fault with your plans before an emergency
then to find out that they fall short during an actual incident. It
is also very important to have a timely post incident critique of all
agencies involved. We have experienced two incidents since this one
and the critiques were used to build upon our existing plans. These
incidents will be discussed in future articles.
Thomas J. Huser, MS, CHSP, is the manager of health and safety risk
management for St. Vincent Hospitals and Healthcare Centers in Indianapolis,
Ind. Huser’s responsibilities include the St. Vincent Carmel Hospital
and approximately 77 off-site locations along with consultation for
seven hospitals that are members of the Central Indiana Health System.
To comment on this article, go to 1601-11 at www.drj.com/feedback.
©Copyright
2003 Systems Support Inc. All rights reserved. Reproduction in whole
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