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.
