NFPA Journal

NFPA Journal®, January/February 2013

By John Farnen and Scott Sutherland

Among the videos posted online in the wake of the tornado that struck Joplin, Missouri, on May 22, 2011, is one taken from a security camera trained on the emergency waiting room in St. John’s Regional Medical Center. The room is empty, save for a couple dozen upholstered chairs and a few tables adorned with magazines. For several moments the action is limited to the pages of a magazine riffling open, as if a breeze is blowing through the room. Then the lights blink and the camera shudders. In the next instant, a torrent of unidentifiable debris blasts into the space; the tables and chairs are swept away, the air fills with projectiles, and dangling wires whip furiously from the ceiling. The lights go out and the video feed begins to blink, but the snapshots that manage to get through capture a hellish scene of unabated violence and destruction. Moments before the feed goes black, a fresh wave of debris fills the space, propelled by tremendous force.

Just steps away from the waiting room, hospital staff were huddled with patients as the building disintegrated around them. The EF5 tornado that struck Joplin late that afternoon was one of the most powerful ever recorded, and the hospital took the full impact of a direct hit, including winds of more than 200 miles (322 kilometers) per hour. As hospital staff executed their “condition grey” emergency plan — moving patients away from windows, gathering in safe areas, closing the doors to patient rooms, and other measures — the tornado blew in doors and windows and destroyed portions of the roof. The nine-story hospital endured the twister’s force for about 45 seconds, and for much of that time powerful winds were able to wreak havoc in the interior of the building. Ceilings were obliterated, water pipes snapped, and hallway walls blown in. Wind got into the stairwells and ripped the sheetrock from the walls. Everything became a projectile: x-ray machines, computer monitors, tree branches blown in from the outside, countless shards of glass. Wind sucked patients, still clinging to their beds, out of safe areas and hurtled them down hallways. When the tornado finally passed, St. John’s had been reduced to little more than a husk, with no power, few usable supplies, and a badly shaken staff. One visitor and five critical-care patients died at St. John’s that afternoon, and were among the 162 fatalities attributed to the Joplin tornado, one of the deadliest in the nation’s history.

Over the subsequent weeks and months, hospital operations were conducted in municipal buildings, tents, hard-sided temporary structures, and semi-permanent module structures. The remains of the 341-bed St. John’s were declared a total loss just days after the tornado, and in January 2012 ground was broken at a nearby site for a new $500 million permanent hospital, to be renamed Mercy Hospital Joplin, scheduled to open in early 2015.

As executive director of strategic projects for Mercy, the hospital’s parent company, John Farnen is responsible for the planning, design, and construction of the new facility. He arrived at St. John’s the day after the tornado hit and was shocked by what he found. “I thought we were prepared for that, but we weren’t,” he says. “We spent the first couple of days just in awe at the amount of destruction.” He spent those first days and weeks handling the myriad problems in front of him — the site had to be secured, radioactive materials and narcotics inside the hospital had to be accounted for, temporary facilities had to be created — but his focus was soon on building a new, permanent hospital. Farnen and other Mercy administrators decided the new facility wouldn’t be business as usual: It would be built to stand up to a powerful tornado in ways that St. John’s could not, thereby limiting damage to the structure and preventing deaths and injuries to patients and staff. “This is tornado country,” Farnen says, “so you need to build to prepare for that.”

Farnen spoke with NFPA Journal about some of the key lessons learned from the Joplin tornado and how they are being incorporated into the design, construction, and emergency planning of the new Mercy Hospital Joplin.

Lesson Learned: Upgrade Windows
The thing that jumped out at you when you looked at the facility was the windows. Almost all of them were broken, and I remember seeing a lot of curtains blowing out of those open windows as we approached the hospital the next day.

During the tornado, losing all those windows meant the interior of the building was immediately open to wind and debris, which caused a lot of havoc and damage in the facility. There were pieces of shattered glass flying around and becoming projectiles. Wind pushed the interior corridors in on the patients who were in the core areas. Wind got up into the ceiling and blew out ceiling tiles, light fixtures, wiring — everything began coming down out of the ceiling and blowing around.

It was a different story in the behavioral health division, though, which used glass that was essentially laminated safety glass. It’s actually a code requirement for behavioral health — there either has to be screens over the windows, or the windows themselves have to be made of safety glass, so that patients can’t break the glass and use it to hurt themselves or others. Those windows cracked, but they stayed in place, withstanding winds that were over 200 miles (322 kilometers) an hour, as well as the impact of all kinds of flying debris.

Maintaining the exterior of the facility is critical in our new plan, and the windows are obviously a big part of that. All of the glass we’re putting in the new facility will be at least 20 percent stronger than the safety glass in the old facility. In a lot of areas, including those that aren’t critical, we’ll use safety glass rated to withstand winds of 140 miles (225 kilometers) per hour. In our critical areas, such as the intensive-care unit, neo-natal intensive care, and pediatric intensive care, the glass will be rated to withstand winds of 250 miles (402 kilometers) per hour, which will also be able to withstand projectiles hitting it at 100 miles (161 kilometers)per hour.

Lesson Learned: Harden the Building’s Exterior Covering
There were also problems with the building’s covering. The old hospital had an exterior insulation finishing system (EIFS), a lightweight synthetic cladding that also includes insulating materials. The problem is that it isn’t as strong, or projectile-proof, as concrete or stone. When you walked around the areas of the hospital that used EIFS, you could see glass shards stuck in it and pieces of metal or two-by-fours that had penetrated it. Some debris can go right through an EIFS.

The new facility will not be covered with EIFS in any of the patient care areas. Building exteriors in those areas will either be reinforced concrete, stone and brick, or precast concrete. The entire exterior skin will be made of a harder material, which will prevent the kind of exterior damage we saw at the old hospital and help prevent the kind of serious interior damage that led to chaos and injuries. 
 
Lesson Learned: Install an Improved Roof System
The old hospital included roofs that were just metal decks with Styrofoam insulation, with roof systems on top of them. Some of those roof systems included ballast, which was actually composed of small rocks like you’d use for landscaping. The tornado picked up all that rock and threw it around with tremendous force, causing a lot of damage. As much as a quarter of the hospital’s roof was destroyed or badly damaged, which was another way wind and a lot of debris got into the building. Fortunately, there were no patients or staff in those areas at the time, and no one was injured as a result of damage to the roof.

Other areas of the hospital had concrete roofs; the tornado might have blown off the roofing material — rubber, typically — but the concrete deck stayed in place. So on the new hospital, all roofs will be concrete with a double roof system and a waterproof membrane that should stay intact.

Lesson Learned: Install a Reinforced Canopy at the Entrance
It’s critical to make sure your entrance remains accessible after an event such as this. There was a pileup of vehicles just outside the entrance, where the tornado had picked them up or pushed them all the way across the parking lot.

To make sure the entrance stays clear, we’re installing a hardened canopy over it, supported by large columns and surrounded by bollards to block any debris heading for the entrance. We’re doing this at the main entrances of all the hospitals in the Mercy system.

Lesson Learned: Harden Stairwells and Exterior Access 
We encountered a lot of problems in stairwells, especially where they went all the way up to a penthouse that opened to the roof.

The tornado blew a lot of those penthouses apart, and the wind blew down into the stair towers and sucked the drywall right off the walls—a lot of it was just screwed into the wall. It was another way the exterior of the building was breached and caused a lot of chaos on the interior. Medical personnel had to maneuver over all that stairwell debris as they evacuated patients from the facility.

Instead of penthouses clad in metal panels, they’ll be built with a hardened board that uses special fasteners that reinforce the construction. We’ll also use storm doors that are stronger and heavier than those that were there before the tormado.

For the interior of the stairwells, we’ll use that same hardened wallboard that the penthouses will be made of; it’s much stronger than drywall, and it won’t crumble like drywall will. It will be held on with additional fasteners and connector systems that will make it much more difficult for wind to shift or remove the panels.

Lesson Learned: Create Hardened Interior Safe Zones
The interior of the hospital sustained a great deal of damage during the tornado. Wind came through all those windows and took down ceilings, blew hallway walls in on patients who’d taken shelter, threw soda machines across entire floors of the hospital, and blew the walls surrounding the building’s elevator cores off, exposing them to the inside of the hospital. Clearly, we needed to create areas in which patients and staff could be safer inside the hospital in the event they needed to take shelter.

The new facility will include designated safe zones for patient evacuation. Essentially, these zones are like storm shelters. If you get a 10- or 15-minute warning for a tornado, it might be impossible to remove some patients from the floor in that amount of time. The idea is to get them away from the windows, get them to the most interior areas on the floor, and then reinforce those areas as best we can to protect them. The hallway walls in the safe areas will go all the way up to the deck above, and floors, walls, and ceilings will all be tied in together with extra structural supports to make the entire interior much stronger and more resistant to external forces.

The ceilings will be strengthened with extra supports. Light fixtures will be anchored with cables, similar to systems used in seismic areas, to help prevent them from falling out of the ceilings. The doors that separate these safe areas from other areas of the hospital will be metal storm doors, which are stronger and heavier than regular interior doors and have stronger surrounding frames.

Lesson Learned: Install Redundant Sources of Primary Power
In the old hospital, we had one source of normal power. Most hospitals are required to have just the one source, not a redundant normal source.

In the new facility, we’re putting in two normal power sources as our first defense. If we lose either one, we’ll still be able to run the whole hospital on the other primary source. Our regional power supplier, Empire Electric, will run the sources in from two completely separate utilities. If we lose a substation, or if we lose the utility, normal power will still have a second transformer substation and power from a different plant. If we lose that, then we can run on the emergency generators, but with a redundant normal source we hope to minimize the need to ever have to resort to a generator for backup power.

Lesson Learned: Harden and Protect Backup Power Sources
Losing power created a lot of problems for us. When the tornado hit, the transformers that provide normal power to the facility were lost almost immediately. The backup power system managed to kick on, but went out a few seconds later. The generators and fuel tanks for the backup system were located outside the building and were destroyed by the air handlers and other debris blowing off the roof. So there was no power of any kind inside the hospital, not even for critical-care areas. There were patients hooked up to life-support equipment that was no longer functioning, and hospital staff were fumbling around in the dark and the debris trying to find the manual equipment to try to care for these people. Electricity is the lifeblood of the hospital, and suddenly losing it, in those circumstances, made things very, very difficult.

The new facility will have a separate central utility plant that will be housed in a hardened concrete structure with storm doors. That structure will be partially buried, and the rest of it will be surrounded by concrete and brick. It will also house the diesel generators for the backup power supply, so they’ll be protected against debris or other external elements, and the fuel tanks will be located underground and similarly protected. Code requires us to keep 24 hours of fuel on hand, but the new emergency power system will have 96 hours of fuel — so this isn’t just a standby system.

A lot of hospitals use standby generators, which aren’t made to run for a week, or a couple of days, or even eight hours. They’re made to run for a few hours at a time, in case you have a power outage or something of fairly short duration. So when hospitals have more serious problems, like a Hurricane Sandy, you hear about standby systems where the generators overheat and don’t stay on, and then you have a big problem. So you need a backup system that will run for a long time. 

Lesson Learned: Install Backup Power for the Backup Power
In the old hospital, when we lost the emergency generators, we lost everything — there was nothing left. In the new facility, critical areas will use an uninterruptible power supply (UPS), which is a battery backup.

Any piece of life-support equipment in the hospital will be on a UPS battery attached to the equipment itself. As long as that equipment is there, it will have a UPS system to power it for a short time until somebody can get to the patients safely. Battery backup will also be installed in stairwells and in the safe areas. Even if we lose power during the day, those interior spaces will still be dark without power, so we need to be able to light those areas to aid with evacuation even if the worst happens and the emergency generators don’t work. 

Lesson Learned: Harden the Emergency Command Center
There was an emergency command center set up in the existing hospital, but without any power and with all the problems in the building, it really couldn’t be used. So it had to be set up nearby, in the convention center of a Holiday Inn, so they could communicate all the emergency numbers and other information to hospital staff and others.

The emergency command center in the new facility will be in a protected space on the lower level, essentially a large conference room with all the communications and other devices in there for the emergency management team. There will also be a portable emergency management trailer, with all the same communications capabilities as the command center, parked at a location other than the hospital. We had a portable trailer for the old hospital, but it was parked at the hospital at the time the tornado hit, which we discovered wasn’t such a great idea, because when we lost the hospital, we lost the trailer, too.

SIDEBAR
Carrying On
The evolution of Joplin’s hospital following
the destruction of St. John’s Regional Medical Center

1 Field Hospital May–September, 2011 A 62-bed tent hospital erected in a St. John’s parking lot opened a week after the tornado struck. The facility included a full kitchen, lab services, an intensive-care unit, a pharmacy, a nearly full-service emergency department, and mobile surgery and imaging facilities. Designed as a military field hospital, the tents can withstand winds of 100 miles (62 kilometers) per hour.
2 Portable Hospital September 2011–April 2012 After spending the summer in the tent facility, most of the temporary hospital had been transferred to a hard-sided component hospital—essentially a series of connected boxes on stilts, situated on a parking lot—by the end of September. The new facility provided better protection against the approaching winter weather. It also offered a welcome increase in space on the inside. At roughly 35,000 square feet (3,252 square meters), it included hallways and semi-private rooms that could accommodate regular-sized hospital beds. The patient capacity was about the same as the tent hospital. Many ancillary services remained located in separate trailers, however.
3 Component Hospital April 2012–March 2015 (projected) Last April, operations were moved into a new, $105 million component hospital. John Farnen, executive director of strategic projects for Mercy, the hospital’s parent company, says building units for the two-story structure were fabricated in California, transported to Missouri by truck and rail, and connected similar to a modular trailer unit. The approximately 160,000-square-foot (14,864-square-meter) facility took about eight months to design and build, Farnen says, and includes 110 beds and four operating rooms. All labs, imaging, and other services are located in the structure rather than in mobile units. The component hospital is equipped with smoke alarms and automatic fire sprinklers.
4 Permanent Hospital Groundbreaking for a new 327-bed, $500 million permanent hospital took place in January 2012. The new facility, located at a site about three miles (five kilometers) from St. John’s, is scheduled to open in early 2015.

SIDEBAR
Emergency Power + NFPA 99 and NFPA 110
Hurricane Sandy highlights the importance of emergency power in health care facilities

By Jonathan Hart

In recent years, an assortment of natural disasters have offered reminders of what can happen to vital emergency power when the weather turns heavy. From Tropical Storm Allison in 2001 to Hurricane Katrina in 2005 to the EF5 tornado that struck Joplin, Missouri, in 2011, and, most recently, to Hurricane Sandy, we’ve seen a steady procession of events that have overwhelmed emergency power systems at health care facilities across the country.

Flooding, the failure of antiquated equipment, and the destruction of supporting infrastructure such as fuel pumps have led to disruption of the essential electrical system, or emergency power, that allows facilities to remain in operation and provide an appropriate level of care and safety to both patients and staff. Among the enduring images of Hurricane Sandy are those of doctors, nurses, and emergency responders evacuating patients down unlit hospital stairwells in New York City, as ambulances lined up for blocks to take them to other facilities.

Some climate experts predict that our future will be filled with more storms and bigger storms, but that doesn’t mean hospitals and other health care facilities need to endure the problems associated with the loss of emergency power.

Two NFPA documents — NFPA 99, Health Care Facilities, and NFPA 110, Emergency and Standby Power Systems — address the primary issues related to emergency power for hospitals. NFPA 99 requires the emergency power, typically provided by generators, and dictates which areas of the health care facility or functions, systems, and equipment must be connected for automatic restoration from the emergency power system.

Certain functions must be restored within 10 seconds of loss of normal power, including those intended for life safety functions, such as illumination of means of egress and exit signs. They also include critical areas and equipment, such as fixed equipment in operating rooms, where the electrical failure can have serious negative consequences on patient care.

Other important, though less critical, building features such as heating equipment and elevators must be connected to the emergency power but are permitted to be restored at appropriate intervals once the energy has been restored to the most vital areas. This power can only be provided when the source of emergency power is properly operating.

NFPA 110, a portion of which is extracted into NFPA 99, addresses this source of emergency power, the emergency power supply (EPS), and, along with its supplementary components, the emergency power supply system (EPSS). (For more on emergency power supply systems, see this issue’s “Electrical Safety” column.)

One of the requirements for locating the EPSS states that the room, shelter, or separate building in which the equipment is housed must be designed and located to minimize the damage from flooding. The associated annex material recommends that the EPSS equipment be located above known previous flooding elevations where possible.

Both NFPA 99 and NFPA 110 address the maintenance and testing of the emergency power systems for health care facilities. Routine maintenance, detailed in NFPA 110, must be performed to ensure that the emergency power can meet the requirement for 10-second power restoration. Monthly testing (at least 12 times per year at intervals between 20 and 40 days) of the emergency power source is required under load for 30 minutes. At least once every three years, the entire EPSS must be tested continuously for four hours.

Hurricane Sandy and the resulting emergency power failures have raised critical questions about the adequacy of these requirements. Why, for example, does NFPA 99 not require more areas or functions within hospitals to be connected to emergency power? Why does NFPA 110 not require that emergency power equipment be located above the known previous flooding levels rather than just minimizing damage from flooding? Are the testing requirements for generators enough to ensure that they will operate over the long durations — days at a time, rather than hours — needed in some disasters? These are all reasonable questions, and the responsible technical committees will most likely address them for the 2015 edition of NFPA 99 and the 2016 edition of NFPA 110.

It is important to keep in mind that these documents are written as minimum standards for the performance, installation, and testing of emergency power systems. Each facility, designer, enforcing authority, or other entity can go above and beyond these minimum requirements at their discretion. When the codes and standards are followed, it is expected that an adequate level of life safety and reliability will be provided. Guidance is available from different groups on going “above and beyond” the minimal requirements, such as The Joint Commission’s Sentinel Event Alert, Issue 37, which specifically offers guidance for health care facilities to reduce the risk of emergency power failure. (For more information, visit jointcommission.org and enter “37” in the search box.)

When failures do occur, requirements in NFPA 99 for emergency management can help reduce the impact (see “Prepping for the Worst,”). Ensuring the reliability of the electrical system is the preferred approach, but proper planning, training, and execution of an emergency operations plan can also make a difficult situation easier to manage. Emergency management includes identifying hazards, developing strategies to mitigate the effects of these hazards, and creating plans for preparing for, responding to, and recovering from the emergency.

The power failures that unfolded in the wake of Hurricane Sandy are being analyzed for lessons we can use to help manage future natural disasters. They remind us how vital the essential electrical systems and their integrity are to health care facilities. While the failures raise critical questions about the requirements of current codes and standards, it is also worth noting that many health care facilities did not require evacuation and that their  emergency power operated properly for the duration of the power outage, allowing them to withstand the influx of patients from those health care facilities that did require evacuation.