Preparing for the "Big One" -- Saving Lives Through Earthquake Mitigation in Los Angeles, CA

HOSPITALS

I. Introduction

The seismic performance of health care facilities is crucialtheir availability and safety can be regarded as a measure of the community's ability to protect its members. Not only do hospitals serve those who are already physically vulnerable, they also must be able, even in the aftermath of an earthquake, to respond to the basic and emergency medical needs of their community. The Northridge earthquake left 8,700 people injured, including more than 1,600 who required hospitalization. There were 82 buildings located on the 23 medical sites (hospitals and skilled nursing facilities) where one or more buildings were forced to evacuate many or all of their patients and personnel, compromising their ability to save lives and provide basic services.

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EXHIBIT 2 Structural damage to wall at Los Angeles County/University of Southern California Medical Clinic.

A number of hospitals suffered significant structural damage in the Northridge earthquake. One hospital was evacuated due to severe diagonal cracking, which extended through the entire thickness of its concrete shear walls. Another was evacuated because of a potential loss of vertical support resulting from column damage. However, from a structural standpoint, recently constructed hospitals in the Los Angeles area withstood the Northridge earthquake relatively well. Comparisons of facilities constructed before and after the 1972 Hospital Seismic Safety Act suggest that the standards established in this law were very important in limiting structural damage; to a lesser extent, the Act was also effective in controlling nonstructural damage.

The real lesson of the Northridge earthquake for health care providers and emergency services planners was that nonstructural damage is a serious threat to patients' safety and hospitals' capacity to function. In two cases, nonstructural damage was so severe that hospitals were forced to close.3 In other facilities, damage to heating and ventilation systems and sprinklers forced major evacuations, even though there was no significant structural damage to the buildings. One State official later referred to the Northridge earthquake as the "nonstructural earthquake."

The significant nonstructural damage caused by this earthquake raises questions about whether current building code requirements for hospitals, which focus on structural elements, are sufficient to ensure that facilities will continue to function after an earthquake. At the State level, the Governor's Office of State Health Planning and Development is already reviewing the adequacy of the Hospital Seismic Safety Act, which it administers.

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EXHIBIT 3 Nonstructural damage to a ceiling at the Pediatric Pavilion, Los Angeles County/University of Southern California Medical Center.

This chapter will focus on the mitigation needs of the public health care facilities operated by Los Angeles County's Department of Health Services (DHS), which provides basic public health care services to Los Angeles area residents, including the medically indigent. It operates 6 acute care hospitals with a capacity of 2,862 beds, as well as 44 health centers that offer basic outpatient services in a community setting. The County's health care facilities also perform a wide range of essential supporting functions. Health centers are local headquarters for environmental specialists concerned with sanitary food and water, while the hospitals also serve as countywide resources for specialized functions such as trauma, burn and psychiatric care, and poison control. Critical information on mitigation plans and estimated costs for medical facilities outside the Los Angeles County system is not available.

II. What Needs to Be Done?

The mitigation needs of health care facilities in the Los Angeles areas whether they are hospitals or clinics, public or privateare necessarily determined by two overriding objectives. The seismic safety of these facilities must be adequate to protect patients, as well as essential equipment and supplies, during and after an earthquake. At the same time, essential systems, ranging from ventilation to communication, must continue to function, so that hospitals and clinics can respond to their community's post-earthquake medical needs.

Los Angeles County Health Facilities

Prior to the Northridge earthquake, the Los Angeles County Department of Health Services had estimated that replacement and modernization of its older facilities would cost approximately $2.3 billion. Now the Department has begun to ask what additional improvements would be necessary to "harden" its critical facilities and communications systems in order to safeguard the integrity of essential services and supplies under severe seismic disaster conditions.

Modernizing and expanding hospital trauma facilities is also critical to adequately providing emergency health care needs after a disaster. The Trauma Facility of the Los Angeles County/University of Southern California Medical Center handles 28 percent of all trauma cases within the County. As the main point of entry to the Medical Center, the Trauma Facility has a patient load of 200,000 visits per year and treats patients from approximately 2,000 paramedic calls each month. Currently, it can only utilize four patient care areas at one time. This severely limits its capacity to provide the highest possible level of care, even under routine operating conditions. To meet the challenge of its growing patient load, as well as future emergencies, the Trauma Facility's capacity needs to double to accommodate eight patient care areas. Other needed improvements include additional radiological and oxygen equipment and storage cupboards and integration of infection control measures into the architectural design. The $2.7 million estimated cost of this expansion/renovation is included in the hospital's overall replacement plan.

Adequate communication also remains a major problem for local disaster response efforts. Disruptions can severely hamper vital coordination activities, such as determining bed availability at various facilities or ascertaining service levels in widely scattered areas. Highly effective radio systems for both the hospital emergency (ReddiNet) and civil emergency (CWIRS) sectors have been developed to meet these communication needs. The Department seeks to enhance the County's CWIRS communication network with the purchase of 110 additional radios at the approximate cost of $300,000. No firm cost for the ReddiNet has been established yet.

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EXHIBIT 4 The Los Angeles County/University of Southern California Medical Clinic, housed in one of the Center's older buildings, sustained such considerable damage that it had to be demolished.

Two potential sources of funds have been identified to pay for these and other improvements. Approximately $23 million from FEMA's Public Assistance program has been earmarked for county facilities, primarily to make emergency repairs and conduct architectural/engineering surveys of damage. On the basis of these surveys, more Public Assistance funds can be authorized for replacement, repair, related code upgrade, and hazard mitigation in damaged facilities. The Department of Health Services also expects to request $400 million from FEMA's Hazard Mitigation Grants Program for seismic upgrade and code compliance-related hazard mitigation projects not covered by Public Assistance. In addition, it is developing cost estimates for projects that would harden essential facilities beyond code requirements eventually, Hazard Mitigation funds may be requested for these projects as well.

However, these Federal resources fall far short of the $2.3 billion needed for planned upgrade and replacement, to say nothing of the unspecified, but surely significant, amount required for hardening projects. Unmet needs also include the matching funds that the County must obtain to leverage Hazard Mitigation Grants. The County anticipates using long-term financing vehicles, such as bond issuances, to cover a portion of the total unmet costs, although recent ballot measures to authorize such bonds have failed.

Community Health Clinics

Together with the County's community-based health centers, community health clinic corporations are the principal source of primary medical care for the indigent. In addition, many community clinics provide a variety of essential social services at relatively low cost. Consequently, they often operate on very small budgets and occupy buildings with low rents. A number of these buildings experienced earthquake damage and were rendered unusable.

Because of their central role as health care and social service providers to low-income households in Los Angeles County, community health clinics must remain operational after an earthquake. These clinics should be encouraged, through incentives such as rent subsidies or space in public buildings, to occupy seismically retrofitted buildings. No reliable estimate of subsidies or suitable publicly owned space for these clinics is available.

III. What Is Being Done?

The Federal Government is contributing to efforts to ensure that Los Angeles hospitals are prepared for the next earthquake both through FEMA grant funds and through direct improvements to hospital facilities of the Department of Veterans Affairs. While the State of California has had difficulty raising funds for mitigation, it is actively pursuing education, training, and coordination activities. In addition, its statutes governing hospital construction have played a crucial role in promoting seismic safety in area health care facilities.

Federal Efforts

As providers of disaster medical relief, the U.S. Departments of Health and Human Services (HHS) and Veterans Affairs (VA) responded immediately to the Northridge earthquake. HHS activated seven Disaster Medical Assistance Teams and the VA activated four mobile health clinicstwo to support the damaged Sepulveda Medical Center and two to meet community medical needs. A total of 1,165 patients were treated by the two community-based mobile VA clinics. VA health care professionals treated three out of every four of the 27,539 persons who received medical services from a Federal health care provider.

The VA's effective disaster response recently prompted the Los Angeles County Department of Health Services to recommend that the Veterans Affairs Medical Center in West Los Angeles serve as a potential Casualty Collection Point site for the County's medical disaster response. As one of these sites, the VA Center would be used for collection, triage, austere medical treatment, longer term holding, and evacuation of casualties in future disasters. The VA Medical Center was also selected because of its geographic location, available response staff, and physical facilities such as a helipad.

The VA has been actively engaged in earthquake mitigation activities since 1971. Through its Seismic Strengthening Program, the VA has spent over $1.1 billion, or approximately $47 million per year, to retrofit its hospitals and ensure that VA facilities are structurally safe. The extent of nonstructural mitigation activities implemented through this initiative has depended on the hospital's location. For instance, VA hospitals in Los Angeles are in the most vulnerable seismic zone and thus warrant major nonstructural mitigation.

Currently, the Veterans Affairs Medical Center in West Los Angeles is reviewing and revising its 5-year retrofitting plan. Needed retrofit and replacement activities affecting 33 of the Center's 140 buildings and structures would cost approximately $41.8 million.

State Efforts

The State of California has enacted important seismic safety laws and continues to coordinate disaster preparedness and ensure that hospital buildings are able to withstand earthquakes. In response, many hospitals have been implementing systematic, long-term mitigation and emergency planning programs. These actions have yielded impressive progress in enhancing the safety and sustainability of the Los Angeles area's health care delivery system.

The Hospital Seismic Safety Act (HSSA)

The Hospital Seismic Safety Act (HSSA) was enacted in the wake of the 1971 San Fernando earthquake, in which several hospitals sustained heavy damage or collapsed. The 1972 law requires that hospitals have special structural features. However, the Act only applies to the construction of new hospital buildings and to the alteration or remodeling of existing structures the Office of Statewide Health Planning and Development has no authority to require that existing structures be upgraded to current standards. Nonetheless, the State and many local jurisdictions are involved in programs to identify and retrofit certain types of older pre-Act buildings to the more stringent seismic standards.

Within 4 months of the Northridge earthquake, amendments to the HSSA were being considered by the California legislature that would make significant changes to the Act. SB1953 recently passed in the Fall, 1994, requiring hospital owners of all buildings determined to be a "potential risk of collapse" to submit plans to replace, retrofit or change use or demolish them by January 1, 2008. Owners of all general acute care hospitals shall either demolish, replace or change use or retrofit buildings that do not meet the requirements of HSSA by January 1, 2030. Hospitals must comply with either of the deadlines or receive an extension in time in order to retain their license. The Department of Health Services, as part of its periodic licensing inspections, would determine the capacity of a hospital to function during and after an earthquake.

The Office of Statewide Health Planning and Development (OSHPD)

The mission of the Office of Statewide Health Planning and Development is to plan for and support development of a health care delivery system that meets the current and future health care needs of the people of California. Among its many functions, the Office conducts plan reviews and field inspections to monitor the structural soundness and functional safety of California's licensed health facilities. It also coordinates with the State Fire Marshal, the Office of Emergency Services, and other affected agencies to maintain the necessary seismic, fire, engineering and construction standards.

Starting in 1979, the Office of Statewide Health Planning and Development began the "General Acute Care Hospital Earthquake Survivability Inventory," which was completed in 1991. State agencies such as the Seismic Safety Commission have used the inventory as a means of assessing the survivability of hospitals in the event of high-intensity ground motions, geotechnical failures, or the failure of utility services.

Governor's Office of Emergency Services (OES)

Since 1991 the Governor's Office of Emergency Services (OES) has been training hospitals in earthquake preparedness and to the benefit of all Californians hospitals have implemented much of what they have learned. This initiative, called the Earthquake Program in California, will accelerate training in the Hospital Emergency Incident Command System, as well as update and continue presentations of a course on "Nonstructural Hazard Mitigation and Emergency Planning." Additional planning and preparedness issues emphasized include training evening and night shift personnel, acquiring better backups for water and power systems, using the Hospital Emergency Incident Command System structure, and developing mitigation strategies to protect essential or hazardous building contents and systems.

Just prior to the Northridge quake, the Office of Emergency Services had started an earthquake preparedness training program for community clinics. This effort is now in high gear. In addition, the clinics are being assisted in the mitigation of selected building contents by teams of California Conservation Corps workers.

Moreover, the Office of Emergency Services is working with the Hospital Council of Southern California and Los Angeles County's Department of Health Services to convene representatives of key health care provider groups and agencies from Los Angeles and surrounding counties in an effort to identify unmet needs and prepare for future scenarios. Formal gathering of data and information on hazard mitigation needs of hospitals, clinics, and long-term care providers has just begun.

Local Efforts

The Los Angeles County Department of Health Services is currently engaged in a comprehensive campaign of disaster recovery/hazard mitigation activities ranging from replacement of its oldest hospital facility to ensuring the continued operational capacity of the newer structures. In some cases, the Department is still in the process of identifying the extent of the physical damage to structures. As late as March 1994, as new aftershocks occurred, some of the structures initially considered safe were evacuated after reevaluation. Structures that pose hazards to human life are being demolished. Temporary, interim facilities are being used to provide medical care, particularly in the San Fernando Valley area. State agencies are reviewing the County's replacement plans for the Los Angeles County/University of Southern California (LAC+USC) Medical Center, the County's largest and most critical facility, which suffered significant damage in the earthquake. The County is also requesting FEMA Hazard Mitigation Grant funding for its undamaged facilities.

IV. Conclusion

Efforts to ensure the seismic safety of the Los Angeles area's public hospital system proceed from a solid foundation. The State of California has provided strategic leadership through vigorous regulation, research, education, and other initiatives. The Hospital Seismic Safety Act offers apparently sound standards for hospital structures, although its provisions for nonstructural elements need attention. Important information on the needs of hospitals in Los Angeles and throughout California is available, and mechanisms for updating and elaborating on this knowledge is in place.

Mitigation plans for Los Angeles County hospitals demonstrate a clear understanding of the mission of the public health care system in a seismic emergency. In the light of this understanding and a careful analysis of damage sustained by its facilities in the Northridge earthquake, the County's Department of Health Services has defined priorities for mitigation. The "nonstructural earthquake" clearly pointed to the need for extensive nonstructural retrofitting. In addition, hardening of essential facilities, structural mitigation or replacement of older structures, and improved communications technology are also required.

Although a reasonable plan for mitigation of health care facilities has been established, the resources needed to implement this plan have not been identified. FEMA Public Assistance funds will be made available to help pay for structural repair of damaged facilities, but are of limited applicability to the system's acute need for nonstructural mitigation and hardening. Hazard Mitigation Grant funds could contribute to addressing these unmet needs; however, the County's ability to raise the necessary matching fundsas well as the much larger amounts needed to carry out mitigation not covered by Federal funding rests on the uncertain prospect of securing public approval for bond issues.

Footnotes

1. Seismic Safety Commission, Draft Response to the Governor's Executive Order Report, January, 1995.

2. Ibid, p. 6.

3. Jo Weber Kimmel, "The Northridge Earthquake; Lessons Learned Concerning Health Care Facilities", California Office of Emergency Services, talking points, Summer 1994.

4. Seismic Safety Commission, "Performance of Hospitals", Interim Background Report B7, June 1994, p. 12.

5. Frank Binch, Network Development Administrator, Personal Health Services, Los Angeles County Department of Health Services, phone interview, September 8, 1994.

6. Ibid.

7. Neither the State Department of Health nor the Los Angeles County Department of Health Services had this information available, September 1994.

8. Letter from the Emergency Medical Services Agency, Los Angeles County Department of Health Services, to Veterans Affairs Medical Center in West Los Angeles, June 2, 1994.

9. Hank Maar, Emergency Preparedness Program Manager, Department of Veterans Affairs, VA Medical Center, Los Angeles, CA, memo, September 29, 1994.

10. Meeting with VA officials, Veterans Affairs Medical Center in West Los Angeles, July 1994.

11. Building Safety Board, "California at Risk Milestone 4 Report, A Recommended Program to Seismically Strengthen Pre-Hospital Act Facilities", December 1990, Sacramento, CA, p. 2.

12. Seismic Safety Commission. Faxed information on SB1953. January 10, 1995.

13. Seismic Safety Commission, "Performance of Hospitals", p. 4.

14. Applied Technology Council, "ATC-23, Part A, General Acute Care Hospital Earthquake Survivability Inventory for California: Survey Description, Summary of Results, Data Analysis and Interpretation", Redwood City, CA, 1991, p. 1.

15. Jo Weber Kimmel, "The Northridge Earthquake".

16. Harriet Glass Ulmer, Los Angeles Regional Director, Center for Health Resources, Hospital Council of Southern California, letter, August 4, 1994.
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