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Disaster mitigation and “Defend in place” Sujayanti Dasgupta, Independent Healthcare Architect
Hospitals are intended to be safe havens where people who are sick and vulnerable go with legitimate expectations of being well-looked after and cured. Under the circumstances, to say that patient safety should be the prime driver that guides norms, regulations and policies in a hospital is only stating the obvious. A robust and well executed Emergency Plan in a healthcare setting becomes the centerpiece in protecting a fragile population against unsettling disasters like flooding, fires, epidemics and the likes. In the light of the AMRI hospital tragedy in Kolkata that tested the facility’s emergency preparedness, many gaping holes have emerged and there is undoubtedly much work needed in this regard.
While there seems to have been several lapses in the facility, the AMRI tragedy particularly highlights an aspect of emergency preparedness that is widely followed but needs thorough scrutiny and reconsideration. The question here is: should hospital authorities continue to follow this practice of total evacuation as first line of defense in an emergency, for a population of patients that is severely limited in its mobility? This may be the common guiding principle but is flawed if one is to accept that a large number of the occupants in any hospital are incapable of self-protection and preservation because of physical limitations and/or age. Additionally, many critically ill patients require the uninterrupted support of life-saving devices, and cannot be moved without serious threats and consequences to their lives. For these reasons alone, hospitals and healthcare facilities in general face exceptional problems, often with disastrous consequences, when it comes to total evacuation.
Assuming that total evacuation is not the best first option then the “defend-in-place” or “protect-in-place” strategy for healthcare settings as popularized and adopted by the National Fire Protection Association (NFPA), USA, among other strategies, becomes a legitimate first line of defense and perhaps the cornerstone of hospital disaster mitigation and patient safety.
“Defend –in-place” requires a drastic paradigm shift and can be broadly divided into a two-pronged approach: minimize movement of the non-ambulatory patient population and protect from smoke that has historically been the cause of most deaths during a fire. The three main pre-requisites for the success of this strategy are:
• Structural integrity: The structure itself is required to be of a construction grade that can withstand several hours of fire without giving way in order for patients and caregivers to remain in place safely. In this type of construction the structural elements consist of noncombustible materials, usually steel or concrete, that provides a given fire protection performance against the effects of fire. It is particularly important to evaluate the structure if an existing structure is being re-used as a hospital. • Smoke Compartments: Each floor of the hospital housing critical and non-ambulatory patients are typically subdivided into two or more (depending on the size of the floor plate) “smoke compartments” separated by smoke/fire-resistant construction. Additionally it requires that each story with inpatients is separated from the one immediately above and below it as smoke zones as well. These zones act as safe locations for patients and caregivers by preventing the spread of fire and the products of fire such as smoke, carbon monoxide and other toxins. Through compartmentalization, patients may remain safely in their rooms as fire suppression systems and fire responders extinguish the fire. Under severe fire conditions that threaten their compartment, patients may be evacuated horizontally through egress corridors to the safety of an adjacent compartment on the same floor. Being able to do this will buy valuable time and save lives of critically ill patients before a total evacuation may become necessary. • Staff Training: It is necessary to point out here that In no other building type does the staff have a more crucial role to play in times of crisis. Their ability to respond appropriately alone can be the deciding factor between life and death. It requires that the staff and caregivers are aware and trained to manage the patient population in an emergency situation. The NFPA requires eight definite actions with respect to staff training for the "defend-in-place" concept. Emphasis is placed on training staff to sound an alarm, handle fire suppression equipment, be able to identify and be familiar with egress routes, be able to monitor patients and relocate if necessary, etc. The decision to utilize the defend-in-place strategy should never be chosen lightly. This is also by no means an isolated strategy for emergency mitigation in healthcare facilities. Rather, it is a preparatory point as well as a parallel track that works in tandem with other traditional methods employed for total building fire protection. The desire to adopt this method necessitates the creation of emergency plans that have to integrate methods by which a fire can be detected early, limited, fought swiftly and successfully. Accomplishing all this requires careful planning at the design level as well at operational levels. It is also imperative that the policies are monitored, tested and evaluated for their effectiveness. After all, any policy is only as good as its implementation.
It requires very little to understand largely avoidable catastrophes such as the AMRI tragedy that are a result of negligence and lack of foresight, pose an additional trauma and hazard to an already vulnerable population - the burden of ineffective life safety procedures, especially in a hospital, is too great to bear and the price, too high.