Risk Management & Safety

Risk & Safety Management in Hospital Constructions and Crisis

Management in case of an Earthquake




Submitted by:
Konstantinos Kostalas
Georgios Pardalis
Maria Xygkogianni








Chalmers University of Technology


2
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Keywoius: iisk management, ciisis management, FNEA tools, vulneiabilities


































S
lnLroducLlon
In the last thiee uecaues, the attituue of society towaius the seismic iisk has
been evolveu fiom fatalistic to pioactive. Nany steps have been maue in oiuei to
pievent fuithei uevastations when a natuial uisastei such as an eaithquake
occuis. Not only the planning piocess befoie natuial uisasteis is impoitant, but
also the post-event management. The noimal opeiation of hospitals in such
ciitical moments is of vital impoitance foi the community, theiefoie theii
iesponsiveness shoulu be immeuiate anu theii level of piepaieuness shoulu be
high.

In the fiist chaptei of this iepoit, uisasteis such as eaithquakes anu theii
consequences aie uiscusseu. The main consequences concein casualties,
economical losses anu infiastiuctuie uisasteis.

In seconu chaptei, hospital uesign consiueiations aie opposeu. Regaiuing an
eaithquake event, iisk management methous aie limiteu to only two stiategies;
pie-event mitigation aiming to the ieuuction of the effects ielateu to life safety
anu uisastei on piopeity anu iecoveiy seivices which ueal with the seivices
pioviueu on the post-event stage.

It is veiy impoitant to consiuei that at the stage of uesign, eveiy builuing has to
follow a ceitain set of iules iegaiuing its use anu the existing builuing coues. Past
expeiience of eaithquakes has leu to moie stiict limitations anu iules iegaiuing
the constiuction of a hospital facility. The evacuation piocess is veiy impoitant
iegaiuing the safety of patients, especially in cases of extieme hazaiuous events.
the evacuation of the hospital anu tiansfei of patients in a safei place out of the
uisastei zone is a choice oiienteu towaius the welfaie of people anu pievents
possible losses of lives. Such a uecision of tiansfeiiing patients to safei places
though, has many iisks that aie neeueu to be taken unuei consiueiation. The
case stuuy of Ippokiateio Bospital of Thessaloniki is useu in oiuei to explain
fuithei anu suppoit the apposeu aiguments. Tools, such as FNEA analysis aie
useu.

The thiiu chaptei of this papei takes into consiueiation the multi-hazaiu
appioach uuiing the uesign piocess. The hazaius causeu fiom eaithquakes to
hospitals give to the uesign stiategies a completely new view. The inteiaction
between the hospital uesign featuies anu mitigation measuies useu to piotect
builuing against an eaithquake event aie uesciibeu. A multi-hazaiu uesign
matiix is chosen, in oiuei to show the inteiaction between potential hazaius
uuiing an eaithquake. A veiy impoitant hazaiu that shoulu be seiiously
consiueieu in builuings such as hospital is the meuical gas.

Regaiuing the fouith chaptei, the level of hospital piepaieuness in case of a post-
eaithquake ciisis is analyzeu. As ciises uue to natuial uisasteis cannot be
pieuicteu, noi avoiueu, society anu authoiities expect that hospitals will be able
to iesponu efficiently to theii iole, anu help towaius the iestoiation of the


4
noimal situation. In oiuei, though, this to be achieveu it is ciucial foi hospitals to
have a cleai view on how they aie going to manage a ciisis situation.

Finally, the conclusions show how vital is the iole of hospitals in the case of ciisis
anu how the potential uisasteis in hospital facilities coulu completely block the
noimal function of the community. Biffeient aspects such as insufficient
piemises uesign, ueficient tiaining piogiam of the peisonnel, pooily uevelopeu
iisk mitigation policies anu failuie in the application of the uevelopeu uesign oi
ciisis plan leau to the uysfunction of the whole system, theiefoie the hospital is
unable to meet its iole.









































S

1. ulsasLers and Lhelr consequences
When the teim uisastei is useu, is usually iefeiieu to an unexpecteu event that is
natuial oi man-maue. The hazaiu causeu fiom this event has as a iesult;
significant physical uamages oi uestiuctions, loss of lives, oi in some cases,
uiastic changes to the enviionment. A uisastei can be extensively uefineu as any
tiagic event stemming events such as eaithquakes, fiies, explosions etc. It is a
phenomenon that can cause uamage to life anu piopeity anu uestioy the
economic, social anu cultuial life of people. Some of the consequences of
uisasteis aie uesciibeu in the illustiation below.




F&10-# KL ;(/+#>0#/4#+ )-(' <&+%+*#-+ MN:8A OPKOQ

The scope of this papei is to examine the consequences fiom natuial uisasteis
anu especially eaithquakes, as well as the aspects of Risk & Safety Nanagement
in Bospital Constiuctions anu Ciisis Nanagement in case of an Eaithquake.
!"! $%&'(%) *+,%,&-(,

A natuial uisastei is a majoi auveise event iesulting fiom natuial piocesses of
the Eaith that can cause extenueu uamages, ueaths, anu complete
uisoiganization in the aiea wheie it hits. A natuial uisastei is always a human-
centeieu event when this uisastei affects iesiuential aieas oi aieas wheie
human activity is uevelopeu(Bankoff et al, 2uuS)
!". /%(&01'%2-

An eaithquake is a natuial phenomenon, in which vibiations anu shoit peiious
of tuibulences aie obseiveu in the soil, anu specifically the ciust of Eaith. Buman
can feel these vibiations, which iun hoiizontal, veitical of coiiugateu anu they
aie accompanieu by seismic waves, which tiansfeiiing anu ieleasing the eneigy
of the eaithquake, causeu by mechanical uistuibance of equilibiium in Eaith's
inteiioi, i.e. bieaking oi movement of iocks of the ciust fiom natuial causes,


6
which usually aie the ielease of compacteu mechanical eneigy anu its
tiansfoimation fiom momentum to kinetic eneigy (0CSB, 2u11).

An eaithquake cannot be pieuicteu, as theie is no efficient methou that can
pieuict such an event. The potential catastiophic iesults of an eaithquake cannot
be avoiueu as the peiiou of its occuiience is shoit anu because the uisastious
iesults that causes cieate a feeling of shock anu awe to people.

Eaithquakes, uepenuing on the cause of theii occuiience aie uiviueu in the
following categoiies 0CSB, 2u11):

Inteiplate eaithquakes
Tectonic eaithquakes
volcanic eaithquakes

In oiuei to be able to estimate the size of an eaithquake anu its possible
catastiophic iesults, foui uiffeient paiameteis aie neeueu to be consiueieu:

!"#$%&"' ") %*+ +$,%*-.$/+: It is the unueigiounu aiea wheie an eaithquake is
boin, wheie the iift on the Eaith's ciust staits anu the mechanical foices cieateu
oveiuiaw the iesistance of iocks.

01&#+'%+, ") %*+ +$,%*-.$/+: It is the veitical piojection of the location of an
eaithquake to the suiface.

2&3+ ") %*+ +$,%*-.$/+: It uesciibes the amount of eneigy ueliveieu anu it is
unique foi eveiy eaithquake. We measuie the size of an eaithquake baseu on
Richtei's scale.

4"#$5 6+1%* ") %*+ +$,%*-.$/+: It is the veitical uistance of the epicentei fiom
the location of the eaithquake, anu it enables us to estimate the possible hazaius
anu uamages that can be causeu in constiuctions.

The examples fiom the seveie uisasteis fiom pievious eaithquakes leu to the
auaptation of moie stiict iegulations foi builuing constiuctions. Paiticulai
attention is given to builuings, which have high level of impoitance, such as
infiastiuctuie ielateu to electiicity, telecommunications etc. anu hospitals.
Especially foi hospitals, iisk analysis is extiemely impoitant, both uuiing the
builuing anu uesign piocess anu ciisis situations, as hospitals aie iequiieu to
help the iestoiation of social balance in cases of such extieme phenomena as an
eaithquake is.










7
2. PosplLal deslgn conslderaLlons
789 :'%,"6.#%&"'

Eaithquake expeiience in uieece uuiing the 1978 anu the 1986 in Thessaloniki
anu Kalamata iespectively, showeu that hospitals aie vulneiable in cases of such
an event anu they may become unable to iesponu to the neeus of the community,
which aie high, especially if the iesult of an eaithquake is catastiophic.

When we have to ueal with an eaithquake event, iisk management methous aie
limiteu to only two stiategies, which aie(Caiuona, 2uu4):

- Pie-event mitigation
- Recoveiy seivices

The fiist stiategy aims to the ieuuction of the effects ielateu to life safety anu
uisastei on piopeity, while the seconu ueals with the seivices pioviueu on the
post-event stage. Bospitals aie those facilities that accept a laige wave of the
post-eaithquake effects, as they have to tieat those injuieu. Theiefoie, it is of
gieat impoitance to foim such mitigation stiategies in the constiuction stage
that will not only piotect the life safety of its occupants, but they will also ensuie
the piopei function of both the builuing opeiations as well as that of theiapeutic
anu uiagnostic anu meuical equipment in the post-eaithquake stage (0' Banley,
1987).

787 ;,+<+=+'% >&%&?$%&"' @%,$%+?&+@

The teim mitigation is iefeiiing to the piocess of ueveloping options anu actions
to enhance oppoitunities anu ieuuce thieats foi life anu piopeity that aie
ielateu to hazaiuous events (PNB0K, 2uuS). Bazaiu mitigation measuies, shoulu
be taken unuei consiueiation uuiing the planning anu uesign of a hospital
because they can ieuuce casualties anu uamages as a iesult of builuing's failuie
uuiing a hazaiuous event (i.e. an eaithquake). The effects of such a uisastei on a
hospital aie not only ielateu to the physical uamage oi the incieasing stiess
factois among the peisonnel, but also with the loss of ability of the hospital to
pioviue the expecteu seivices in a case of this hazaiuous event. Enhancing
mitigation measuies uuiing the uesign piocess of the hospitals is theiefoie of
gieat impoitance, because the possibility of uisiuption of hospital opeiations is
minimizeu anu the whole facility is piotecteu anu ieauy to pioviue the seivices
neeueu in ciitical cases.

78789 A@@+@@&'? ,&@/

At the stage of uesign, eveiy builuing has to follow a ceitain set of iules
iegaiuing its use anu the existing builuing coues. The sau expeiience of past
eaithquakes has leu to moie stiict limitations anu iules iegaiuing the
constiuction of a hospital facility. The majoi questions, uuiing the uesign piocess
of a hospital, that neeu to be answeieu aie the following(Boe, 2uu2):


8

What types of anu magnituues of hazaiu events aie anticipateu at the
site.
What aie the vulneiabilities of the site (oi the existing builuing in case of
ienovation) to natuial hazaius.
What aie the anticipateu fiequencies of hazaiu events.
What level of loss is acceptable.
What might be the social anu financial impact of extenueu uowntime on
the facility.
What is the impact to the community in case the hospital cannot maintain
opeiations aftei a hazaiuous event.

Apait fiom these questions, the fact that theie is no way to cieate a facility that is
going to be 1uu% safe against any possible uamage, causeu by an inciuent such
as an eaithquake, shoulu be accepteu. Bence, a facility with the least possible
iisk chance is neeueu to be cieateu.
78787 0=$#.$%&"' #"'@&6+,$%&"'@

In cases of extieme hazaiuous events (i.e. a laige scale eaithquake) evacuation of
the hospital anu tiansfei of patients in a safei place out of the uisastei zone is a
choice oiienteu towaius the welfaie of people anu pievents possible loses of
lives. Such a uecision though, has many iisks that aie neeueu to be taken unuei
consiueiation. The iesponsibilities against those iisks aie stateu cleaily fiom the
uieek 0ffice of Civil Piotection(2uu7): "When the uecision to evacuate a health
caie facility is taken, authoiities must alieauy have ensuieu foi the cieation of a
safe sheltei, which will have all the available iesouices foi patients' caie. It is
also ciucial tianspoitation to be available to move patients in othei ieceiving
facilities out of the uisastei aiea".

The evacuation scenaiio is not an easy task. Nany patients have limiteu mobility
oi othei aie unuei ciitical life suppoit. In oiuei the evacuation scenaiio to be
successful, the uevelopment of an efficient plan is neeueu anu the tiaining, on the
highest possible level, of the staff is iequiieu. Past expeiience cieateu the neeu
foi the uevelopment of effective evacuation plans. The use of Failuie Noue &
Effect Analysis (FNEA), pioviueu expeits with a stiong tool towaius the
impiovement of evacuation piocesses. FNEA is a methou uesigneu to (Stamatis,
199S):

- Iuentify anu fully unueistanu potential failuie moues anu theii causes, anu the
effects of failuie on the system oi enu useis, foi a given piocess.
- Assess the iisk associateu with the iuentifieu failuie moues, effects anu causes,
anu piioiitize issues foi coiiective actions
- Iuentify anu caiiy out coiiective actions to auuiess the most seiious conceins

A Failuie Noue & Effect Analysis is uiviueu in nine steps, which aie:
1. Befine pioject scope
2. Bevelop flow chaits
S. Iuentify all ways piocess coulu fail


9
4. Rate each possible failuie moue
S. Beteimine the iisk scoie
6. Calculate piimaiy outcome measuie
7. Iuentify failuie moues gieatei than a uesignateu scoie anu uevelop action
plan
8. Piopose steps to implement action plan
9. Rescoie the piimaiy outcome measuie

In oiuei to unueistanu how the FNEA tools woik, an example stuuy case is
apposeu baseu on ieal life facts.

Scenaiio: The scenaiio is baseu on one of the majoi hospitals in the city of
Thessaloniki, Ippokiateio hospital. Thessaloniki is a city, which in the past uealt
with seveie uamages because of the majoi eaithquake of 1978. The whole
evacuation plan of the hospital is being upuateu eveiy S yeais anu it is
consiueieu one of the most well stiuctuieu plans in uieece. Because of the laige
capacity of the hospital, we have ueciueu to make a simulation of the evacuation
plan foi the most ciitical paits of the hospital, which aie the &'%+'@&=+ #$,+
.'&%@. In oiuei to make oui mouel simplei, we placeu all the intensive caie units
on the same builuing (in ieality they aie uiviueu in two uiffeient builuings in
uiffeient aieas of the hospital). Theii capacity is uesciibeu below:

- Intensive Caie-Neonate (SSbeus 4
th
flooi)
- Peuiatiic intensive Caie (12 beus 4
th
flooi)
- Suigical intensive Caie (1u beus 2
nu
flooi)
- Caiuio-Thoiacic suigical intensive caie (12 beus 2
nu
flooi)
- Neuical intensive caie (1u beus 2
nu
flooi)
- Coionaiy caie (Su beus 2
nu
flooi)

Total: 1u9 beus

The evacuation flowchait in case of an eaithquake oi anu ielateu hazaius, is
piesenteu below:



1u




F&10-# OL =J%40%*&(/ F2(B4"%-*



0>+,?+'%B Builuing collapse, Neuical gas failuie, plumbing
Timefiame: immeuiate evacuation (<1S minutes)
C,?+'%B Powei failuie, elevatoi failuie
Timefiame: Evacuation in 2-S houis
05+#%&=+B Constiuction iestoiation
Timefiame: Seveial uays



11
Aftei ueveloping the flow chait, it is neeueu to iuentify the failuie moues at each
pait of the piocess, steps that aie illustiateu on the flow chait. We neeu to
iuentify the cause anu effects of those failuies anu be able to "pieuict" why each
of these failuie moues might happen. In oui case, some of the iuentifications why
oui piocess might fail aie (Figuie S):

- Insufficient staff foi unit evacuation
- Insufficient space to maintain patients at final evacuation location
- Shoitage of meuication at final evacuation location
- Insufficient electiical meuical gas infiastiuctuie foi patient suppoit at final
location
- Patient movement issues ! veitical evacuation
- Insufficient equipment foi veitical evacuation
- Safe aieas foi evacuation not iuentifieu
- Planneu evacuation ioute is blockeu
- Tiaffic jams when moving patients with inability to move
- Automation in the hospital (automatic uoois, access caiu ieaueis etc.) may not
woik
- Elevatois close to the neaiest evacuation point aie out of oiuei
- The seveiity of the event is assesseu wiong (leaus to faulty event iesponse
uigency)
- Insufficient lighting foi patient evacuation
- Nisiuentification of the numbei of patients impacteu
- No alteinative ioutes foi veitical evacuation




F&10-# RL F&+"I(/# ;"%-* () *"# +*0<3 4%+#





12
Baving assesseu all these paiameteis that might leau to failuie, we pioceeu in
iating each failuie moue. Buiing this piocess we have to take unuei
consiueiation thiee factois:

- 2+=+,&%DB Is the consequence of the failuie shoulu it occui
- ;,"E$E&5&%D ") F##.,,+'#+B Is the likelihoou of a failuie moue occuiiing
- G+%+#%&"' H$%&'?B Is the ability to catch the eiioi befoie causing haim to
patients

In oiuei to piioiitize all the possible failuies, we ueteimine theii Risk Scoie by
using the following foimula (Stamatis, 199S):

Hisk ;iioiity Iumbei = Seveiity * 0ccuiience * Betect Ability

Each of the paiameteis is measuieu in a scale fiom 1 to 1u anu the iesulting
numbei is between 1 anu 1uuu. If the RPN foi a failuie moue is equal oi below
1uu, then the pioblem uesciibeu fiom this failuie moue is of minoi impoitance.
A template foi RPN that is useu in Risk analysis is like the one piesenteu below:



F&10-# SL F%&20-# 9(<#+ %/< =))#4*+ C/%23+&+ !#',2%*# MD/+*&*0*# )(- :#%2*"4%-# D',-(J#'#/*A OPPSQ

Baseu both on the expeiience fiom the eaithquake of 1978 in Thessaloniki anu
the example of Kalamata's eaithquake in 198S, the Failuie Noue RPN scoies aie
illustiateu in the following table:




1S
Insufficient staff foi unit evacuation
Suu
Insufficient space to maintain patients at final evacuation location
Suu
Shoitage of meuication at final evacuation location
Suu
Insufficient electiical meuical gas infiastiuctuie foi patient suppoit
at final location
Suu
Patient movement issues ! veitical evacuation
Suu
Insufficient equipment foi veitical evacuation
Suu
Safe aieas foi evacuation not iuentifieu
Suu
Planneu evacuation ioute is blockeu
2Su
Tiaffic jams when moving patients with inability to move
2Su
Automation in the hospital (automatic uoois, access caiu ieaueis
etc.) may not woik
2Su
The seveiity of the event is assesseu wiong (leaus to faulty event
iesponse uigency)
8u
Nisiuentification of the numbei of patients impacteu
8u
Insufficient lighting foi patient evacuation
Su
No alteinative ioutes foi veitical evacuation
4S
!%I2# KL 5%/6#< F%&20-# 9(<# 84(-#+

J*+ %"%$5 ") $55 H;I @#",+@ &@B K9LM
Compaiing this scoie with scoies fiom othei hospital, it shows that the majoi
possible failuie moue events have been pieuicteu coiiectly.
The next phase of the analysis iequiies the iuentification of an action plan. We
neeu to iuentify those failuie moues that have a RPN scoie fiom 1uu point anu
above, because these aie the items that aie moie ciitical, so we neeu to pay moie
attention. It is ciucial to uevelop an action plan to auuiess each of those high-
hazaiu scoie failuie moues. In oui case stuuy pioposals foi solutions might
incluue:

- Iuentify anu maik safe aieas of iefuge on the 2
nu
anu 4
th
flooi
- Iuentify piimaiy anu seconuaiy evacuation ioutes
- 0puate the existing emeigency evacuation opeiations plan
- Iuentify anu assign teams to evacuate the pioposeu aieas anu teams that aie
going to opeiate at the safe place
- Cieate a mastei equipment anu meu inventoiy list
- Conuuct a stuuy anu cieate the necessaiy infiastiuctuie at the safe point
- Piepaiation with alteinative souices of eneigy in case of powei failuie
- Bevelop unit-baseu emeigency evacuation guiues (immeuiate iesponse)
- Tiaining of all the staff of the hospital, anu conuuction of veitical Evacuation
Simulations in fiequent basis

Aftei implementing the action plan, we iecalculate the RPN scoies anu we
compaie them with those of the fiist FNEA analysis. The expeiience in similai
analysis that have been contacteu in cases such as Washington anu Califoinia
hospitals, showeu that the items uuiing the ie-calculation piocess weie
auuiesseu with a scoie that was significantly ieuuceu, compaieu to the piimal
giauing. The oveiall iesult has been ieuuceu by an aveiage of 7u%, which make
these plans effective anu acceptable (FENA, 2uu7).



14
."."3 45&-6&+%) 7')6-(%8+)+&+-,

Bospitals aie on the coie of piotection anu safeguaiuing of health anu well being
in communities. The iole of hospitals becomes moie ciitical in cases of
hazaiuous events, so it is impoitant that they shoulu be able to opeiate in an
effective way uuiing the afteimath peiiou of a uisastei causeu by an eaithquake.
Bospitals aie complex systems, with complex opeiations anu even the smallest
uis-function oi bieakuown uisiupts the haimonic opeiation of that system. That
makes hospitals vulneiable to possible hazaius, theiefoie it is of gieat
impoitance measuies to be taken to ueciease the level of vulneiability of this
system. In the uesign phase, thiee main aspects shoulu be taken unuei
consiueiation, iegaiuing the vulneiability of hospitals, which aie:

- 2%,.#%.,$5 =.5'+,$E&5&%DB The uesign of the stiuctuial system of the hospital
shoulu auuiess to the potential maximum hazaiu foices. In auuition, the
builuing mateiials anu the constiuction piocess shoulu be selecteu anu
contacteu caiefully anu accoiuing to the highest possible stanuaius. Lastly, the
aichitectuial anu stiuctuial foim of the builuing shoulu be such that will
enable the safe anu immeuiate evacuation of the site in case of an extieme
hazaiuous event, anu allow the main functions to be opeiateu on site(B0E,
2uu2).
- I"'@%,.#%.,$5 =.5'+,$E&5&%DB Past expeiience showeu that uuiing hazaiuous
events, seveie uamages in the non-stiuctuial components of builuing causeu
seiious acciuents anu equipment uamage uuiing the evacuation piocess.
Bamages to ioof coveiings, winuows, pipes etc. have leu to even majoi uis-
function that causeu pioblems in the noimal opeiation piocess of a hospital.
Bence, it is neeueu those nonstiuctuial components to be caiefully selecteu
anu placeu on site, so they can cause the minimum possible potential pioblems
(B0E, 2uu2).
- F,?$'&3$%&"'$5 =.5'+,$E&5&%&+@B All the hospitals aie obligeu to emeigency
opeiations plans, but a vast majoiity of them have not pieuicteu oiganizational
plans in case of emeigencies. Lack of such plans may leau to chaos situations in
case of emeigency anu it will uisiupt foi suie the noimal opeiation of a
hospital in times when it is most neeueu. Such plans neeu to also incluue
effective piocuiement plans anu an auministiative stiuctuie that will allow the
mission of a hospital to be met. In auuition to the evacuation plan that has been
analyzeu above, it is also impoitant that hospitals iequiie the help of the
authoiities in oiuei them to pioviue all the necessaiy seivices (ioutes foi
patients ueliveiy on time, communications etc.) when it is most neeueu (Woilu
Bealth 0iganization, 2uu6)











1S
3. PosplLal ueslgn & ConsLrucLlon
K89 :'%,"6.#%&"'

The neeu foi uninteiiupteu opeiation of hospitals, even in cases of hazaius, is
uemanuing anu is one of the main chaiacteiistics of hospital facilities. That
makes the uesign of such facilities ieally challenging, as it is ciucial the
mitigation measuies to be stiict anu iesponu to eveiy challenge. Bospitals host a
gieat numbei of people on a uaily basis, so the builuing uesign has to be suitable
foi all the uiffeient complex opeiations that take place theie, even in cases of
emeigency. The olu uesign policies uiu not take unuei consiueiation the
aujustment of the hospital opeiations in cases of emeigency, like those of post-
uisastei, fiom an eaithquake.

Bospitals aie not consisteu by only a single builuing. Bospitals aie locateu on a
campus with a numbei of uiffeient builuings, with each one of them housing
uiffeient functions. Auministiative seivices, powei plants, meuical gas piemises
anu uiffeient wings constitute the whole complex system of a hospital. Fiom a
safety point of view, these builuings uo not stanu on the same uisastei-iesistant
level of constiuction. The constiuction of these builuings is iuleu by a ceitain
amount of builuing coues.

K87 N.&56&'? O"6+@

Eveiy state has uevelopeu a ceitain amount of builuing coues that uesciibe how
builuings aie constiucteu, uepenuing on the functions they suppoit. uieece,
baseu on the pievious sau expeiience fiom eaithquake uisasteis, the whole set
of anti-seismic builuing coues has been ievieweu (latest ieview in 2uu8). While
most builuings' coues auuiess to minimum iequiiements foi builuings against
majoi hazaius, builuing coues in uieece facing the uesign of hospital builuings
with the same iigoi encounteieu in the uesign of heavy inuustiy builuing anu
laige powei plants. Nost essential facilities iequiie special attention, in auuition
to compliance with uesign iequiiements, in oiuei to be able to sustain theii
opeiations on the post-uisastei peiiou. In oiuei this to be achieveu multi-hazaiu
appioaches have been uevelopeu in the uesign piocess of hospital builuings.
K87 P.5%&<*$3$,6 #"'@&6+,$%&"' &' 6+@&?' 1,"#+@@

The hazaius causeu fiom eaithquakes to hospitals gtuc to the uesign stiategies a
bianu new view. All the iisks have staiteu to be consiueieu on the infancy stages
of such a constiuction anu a multi-hazaiu appioach has been uevelopeu with a
cleai goal to integiate iisk ieuuction foi the final stiuctuie(B0E, 2uu2). Below
the inteiaction between the hospital uesign featuies anu mitigation measuies
useu to piotect builuing against an eaithquake event, is uesciibeu. This
inteiaction is only a pait of the laigei integiateu appioach to the whole builuing
uesign piocess.




16
K8789 Q*D $ >.5%&<*$3$,6 $11,"$#* &@ #*"@+'

When hospital builuings aie locateu in aieas of high seismic potentiality, the
neeu to embiace a multi-hazaiu appioach in the uesign piocess becomes
essential foi theii piotection. The multi-hazaiu appioach helps in the
iuentification of possible conflicting effects of ceitain mitigation measuies anu
makes hospitals as a whole complex system, less vulneiable (B0E, 2uu2). A
compiehensive evaluation anu application of hazaiu mitigation in builuing
uesign iesults in the impioveu effectiveness of mitigation measuies anu enable
the hospital to continue opeiating without inteiiuption of its functions.

An impoitant aspect of multi-hazaiu appioach in hospital builuing uesign shoulu
be the investigation of the level to which methous use foi mitigation of one
hazaiu conflict with those of othei hazaius. When the uesign mitigation methous
enfoice each othei, the oveiall peifoimance of the builuing is impioveu (safe
builuing conuitions), while in the opposite situation we may leau to a uomino
effect with catastiophic outcomes (B0E, 2uu2).
K8787 P.5%&<*$3$,6 6+@&?' >$%,&R

The multi-hazaiu uesign matiix shows the inteiaction between a paiticulai
hazaiu anu a builuing uesign component oi system (Caiuona, 2uu4). Below, the
inteiaction between potential hazaius uuiing the eaithquake is piesenteu, with
a small explanation of the natuie of inteiaction anu a small piesentation of each
builuing chaiacteiistic. The inteiaction is chaiacteiizeu as positive, negative oi
neutial anu is iepiesenteu by the colois shown on the illustiation below. In
oiuei to make the compaiison moie iealistic in a case of an eaithquake, the
authois have auueu some hazaius that may occui aftei a seismic inciuent (but
they can occui even on theii own). These hazaius aie fiie anu floou.



Inuicates a uesiiable conuition oi beneficial inteiaction between the uesignateu
componentsystem anu a given hazaiu

Inuicates an unuesiiable conuition oi the incieaseu vulneiability of a uesignateu
componentsystem to a given hazaiu
Inuicates little oi no significant inteiaction between the uesignateu
componentsystem anu a given hazaiu
!%I2# OL ;(',%-&+(/ I#*B##/ "%@%-<+












17
# Site & Builuing
Chaiacteiistics
Seismic Floou Fiie Explanation of inteiaction
1 Site-specific anu
builuing specific all-
hazaiu analysis.
Beneficial foi all hazaius
2 Two oi moie means
of access to the site
Beneficial foi all hazaius
S Two oi moie
evacuation ioutes
fiom the site
Beneficial foi all hazaius
4 Encloseu couityaiu
plan foims
Nay cause stiess concentiations anu
toisional foices in eaithquakes.
S Beavy stiuctuie
with conciete floois,
ieinfoiceu conciete
moment fiame, oi
fiame with
ieinfoiceu conciete
oi masoniy sheai
walls
Although weight incieases seismic foices
it is not a uesign pioblem. Requiies
special non-uuctile uetailing foi laige
builuing fiames. ueneially beneficial foi
all othei hazaius
6 0nieinfoiceu
masoniy loau-
beaiing walls
veiy pooi peifoimance in eaithquakes
anu high winus. 0nuesiiable foi all
hazaius because of possibility of collapse.
7 Laige seismic
sepaiation joints in
stiuctuie
Impioves seismic iesponse, but cieates
possible path foi
toxic gases uuiing fiie
8 Biick veneei on
exteiioi walls
In eaithquakes, winus, anu floous
mateiial may uetach anu cause costly
uamage anu injuiy. Caieful uetailing anu
quality contiol necessaiy foi goou
peifoimance.
9 vibiation-isolateu
equipment uesigneu
foi seismic foices:
snubbeis pievent
equipment fiom
falling off isolatois
veiy beneficial foi eaithquake, not
significant foi floou oi fiie.
1u Anchoiagebiacing
of system
components
Essential foi eaithquake, beneficial foi
fiie
!%I2# RL D/*#-%4*&(/ I#*B##/ I0&2<&/1 4(',(/#/*+



18
3"3 9-*+:%) ;%, <56,+*-(%&+56,

It is veiy impoitant to seiiously consiuei meuical in the hospital as past
expeiience showeu that in a case of eaithquake the stoiage systems of meuical
gas aie listeu among the most vulneiable systems.
In hospitals, the main uses of meuical gas concein suigeiies, life suppoit etc. The
gas is usually supplieu by compiesseu gas cylinueis, which aie placeu in
hospitals' basements oi thiough unueigiounu piping systems, by gas tanks.


Bangeis aie usually poseu uue to impiopei anchoiing anu tanks that aie built
without stiict iegulations. These uangeis may leau to uisastious events of
extieme seveiity, which will not allow hospitals to fulfill theii mission in ciisis
moments, anu eventually will cost lives(ATC, 2uuS).

K8K89 O">1,+@@+6 ?$@ #D5&'6+,@

Compiesseu gas cylinueis usually contain oxygen, nitiogen anu nitious oxiue
anu aie often attacheu to manifolus. Compiesseu gas cylinueis constitute the
only souice of meuical gas, in hospitals wheie no gas tanks aie built. When an
eaithquake happens, uniestiaineu cylinueis aie likely to topple anu bieak theii
connections with the manifolus. In auuition, uue to impiopei anchoiing,
cylinueis that aie stoieu as back up in cait oi stoiage cages, aie also likely to fall,
be bioken anu eventually this will leau to gas leak(ATC, 2uuS). Pictuies of gas
cylinuei batteiies anu gas cylinueis stoiage aie shown below (pictuies 1 & 2).


T&4*0-# KL E%+ 432&/<#-+ I%**#-3 MU%63/*"(+ "(+,&*%2Q



19

T&4*0-# OL E%+ 432&/<#-+ &/ +*(-%1# 4%1# M;%2&)(-/&% V8:TNQ

In the case that cylinueis bieak fiee fiom manifolus, the supply of meuical gas
will be paitially oi entiiely inteiiupteu. That cieates a ciitical situation foi those
patients who aie in neeu of this kinu of life suppoit. The gas leakage itself cieates
a ciitical situation as well, especially insiue the builuing of the hospital.


P+%*"6@ ") $'#*",&'?

Anchoiing compiesseu gas cylinueis is quite easy. It is just iequiieu chains with
quick ielease clasps to stiuts oi angles that aie fasteneu secuiely to the wall to
be installeu (Pictuie S). 0ne stiut shoulu be placeu at 2S of the height of the
cylinueis, anu the othei neai the bottom of cylinueis. Fasten the chains aiounu
the cylinueis. Ensuie that the wall is stiong enough to iesist the foices that the
cylinueis aie geneiating (FENA E-74, 2u12).



T&4*0-# RL C/4"(-&/1 () 1%+ 432&/<#-+ MF=9C =HWSA OPKOQ

Anothei option is to install a special iack foi the cylinueis as it is shown on
pictuie 4. The manifolus can be built in to the iack, anu the iack is secuieu to the
wall. Cylinueis aie fiimly anchoieu to the iack but can easily be iemoveu by
loosening the wing nut anu tuining the iestiaint ninety uegiees (FENA E-74,


2u
2u12). This methou is moie expensive, but cylinueis can be spaceu much moie
closely than when using the chain anu stiut methou.


T&4*0-# SL ;32&/<#-+G -%46 MD,,(6-%*#&( "(+,&*%2Q

K8K87 P+6&#$5 ?$@ %$'/@

When an eaithquake happens, it is veiy likely the meuical gas tanks to cause
laige foices on the suppoit uue to theii size (they aie usually tall with small
uiametei). Stiong shaking can cause meuical gas tank suppoits to fail, anu the
tank can topple. That is causeu because the anchoi bolts that holu the tank to the
suppoit fiame aie too weak to iesist the foices cieateu (Pictuie S).


T&4*0-# XL F(-4#+ 4-#%*#< (/ % '#<&4%2 1%+ *%/6 MU%63/*"(+ "(+,&*%2Q

The patients aie not the only ones who can be affecteu fiom such a situation
because of the meuical gas supply cutting off. This can even leau to an explosion,
as these tanks contain oxygen which cieates a seveie fiie hazaiu. In such a case,
anu the aiea is neeueu to be evacuateu immeuiately.



21
P+%*"6@ ") $'#*",&'?

In oiuei to achieve the best possible iesult consiueiing the anchoiing of a
meuical gas tank an engineei shoulu ueteimine if the suppoit system of the tank
is stiong enough to iesist to maximum level of eaithquake shaking. The engineei
is the one iesponsible to check the anchoi bolts, the tank legs themselves, anu
the welus that connect the legs to the tank. Theie aie cases that tanks neeu a
stiongei founuation oi ieinfoicement of the existing fiame. it is also iequiieu
iigiu connection to the supply system to be ieplaceu by othei, moie flexible,
connections (ATC, 2uuS).














































22
4. PosplLal preparedness ln case of an posL-
earLhquake crlsls
S89 :'%,"6.#%&"'

It is common knowleuge that ciises can neithei be avoiueu noi accuiately
pieuicteu. Especially when an eaithquake inciuent occuis, society anu
authoiities expect that hospitals will be able to iesponu efficiently to theii iole,
anu help towaius the iestoiation of the noimal situation. In oiuei, though, this to
be achieveu it is ciucial foi hospitals to have a cleai view on how they aie going
to manage a ciisis situation.
S87 G+)&'&%&"' ") #,&@&@ T #,&@&@ >$'$?+>+'% #D#5+

Bictionaiies uefine ciisis as "Ciitical event oi point of uecision which, if not
hanuleu in an appiopiiate anu timely mannei (oi if not hanuleu at all), may tuin
into a uisastei oi catastiophe" (0xfoiu uictionaiy, 2u12). A ciisis cieates a
suuuen situation oi a situation that takes some time to evolve anu always leaus
to an uigent pioblem that must be auuiesseu immeuiately. As it is stateu above,
a ciisis is unpieuictable, but it is a situation that can be expecteu. Efficient ciisis
management policies shoulu be able to iuentify potential causes of ciisis anu
uevelop a plan of immeuiate iesponse, when it is necessaiy. Eveiy ciisis is
uevelopeu in uiffeient phases, which neeu to be thought when a ciisis
management plan is uevelopeu. These phases aie (Callahan et al, 2uu8):

- ;,+1$,$%&"'B Bealing with issues, like planning, euucation anu tiaining
- P$'$?+>+'%B Bealing with issues, like allocation of iesouices, commanu anu
communication systems
- 0=$5.$%&"'B Lessons leaineu in post ciisis phase anu use this knowleuge foi
impioving policies.


F&10-# XL ;-&+&+ 9%/%1#'#/* ;342# M;%22%"%/A #* %2?A OPPYQ







2S
;,+1$,&'? )", #,&@&@

A ciisis management stiuctuie is neeueu to be cieateu in oiuei to cooiuinate
actions uuiing a ciisis event. Contiol gioups anu opeiational gioups neeu to be
foimeu anu ioles have to be assigneu to inuiviuuals. Public Piotection has
usually templates of such stiuctuies to suppoit this function, but oiganizations
(i.e. hospitals) aie able to foim theii own. Thiough the planning piocess all the
possible events that may occui must be pieuicteu, in oiuei the oiganization to be
piepaieu to ueal with them in an effective way. It is also impoitant uiffeient
ciisis scenaiios to be uevelopeu, in oiuei the most effective iesponse plan to be
ueteimineu. The execution of simulation exeicises is also of gieat impoitance, as
people who aie involveu in ciisis situations test theii skills anu have the ability
to fix possible insufficiencies (Callahan et al, 2uu8).


F&10-# ZL N&))#-#/* *3,#+ () 4-&+&+ #.#-4&+# M;%22%"%/ #* %2A OPPYQ


P$'$?&'? #,&@+@

Naking plans to ueal with a ciisis situations, anu actually ueal with such a
situation aie two completely uiffeient concepts. Past expeiience showeu that the
assuiance of a uetaileu ciisis management plan, leu to significant eiiois uuiing
its application in actual ciisis moments. It is often new pioblems to occui on spot
anu uecisions to be maue baseu on the expeiience of those involveu. The line of
authoiity anu the iesponsibilities of inuiviuuals neeu to be iuentifieu, anu people,
uespite the fact that they have to opeiate inuepenuently, neeu to be cooiuinateu
in an efficient way. In oiuei this to be achieveu, an integiateu commanu system
neeus to be foimeu(Noynihan, 2uuS). An ICS might be like the one illustiateu at
the figuie below.


F&10-# WL 9(<#2 )(- %/ &/*#1-%*#< 4(''%/< +3+*#' M9(3/&"%/A OPPWQ


24

The use of stanuaiu opeiating piotocols can be a valuable assistance in
managing a ciisis. That stanuaiuization though, can limit flexible iesponses, anu
eventually people insteau of taking initiative when it is most neeueu might stuck
in what is wiitten anu testeu. It is also ciucial in the pie-ciisis peiiou, that
infoimation is gatheieu iegaiuing the facts that may occui on the post-ciisis
peiiou. Such infoimation foi hospitals is the amount of people that aie expecting
to host, the ioutes foi ueliveiy of patients, the meuical cases that they will have
to ueal with etc.(Callahan et al., 2uu8).

;"@%<#,&@&@ +=$5.$%&"'

The examples of past ciises anu the way in which hospitals have uealt with them,
have affecteu in a gieat extent the way that hospitals hanule with ciises
situations nowauays. Eveiy ciisis has its own chaiacteiistics anu its own impact
upon the complex systems, as hospitals. In post-ciisis phases, the lessons leaineu
help those iesponsible to make impiovements to alieauy establisheu ciisis
management plans anu make a fuithei ieview on oiganizational anu opeiational
level.
S8K U"@1&%$5 1,+1$,+6'+@@ $'6 ,+@1"'@+ &' +$,%*-.$/+ #,&@+@

Najoi eaithquakes can cause unpieceuenteu catastiophes. With eaithquakes as
an inevitable pait of oui futuie, hospitals shoulu make plans anu take actions to
ensuie that uisasteis uo not become catastiophes. Whatevei the level of ciisis oi
uisastei is, piepaieuness is the key to suivival. The oveiall impact of a seveie
seismic event can be huge anu long lasting (Kaji, et al., 2uu7). Past expeiience
fiom majoi eaithquakes in uieece anu in global level showeu that societies
stiuggle to get back in noimal living stanuaius, anu that makes the iole of
hospitals in such ciises even moie impoitant. The key point fiom hospitals is to
get back as soon as possible to the noimal seivice function. The illustiation
below shows how the level of seivice is foimulateu uuiing a catastiophic
eaithquake event.




F&10-# YL [0%2&*3 () "(+,&*%2 +#-J&4#+ <0-&/1 % "%@%-<(0+ #J#/*


2S
S8K89 H+$6&'+@@ %" >$'$?+ &'V.,&+@ $'6 #$@.$5%&+@

Following a catastiophic eaithquake, hospitals neeu to be ieauy foi an influx of
injuieu people anu people that aie alieauy ueau. 0n time ueliveiy of injuieu
people to meuical caie can save lives. Reseaiches showeu that the uelayeu
tianspoitation of those wounueu with lightei of heaviei injuiies, has leu to an
incieaseu ueath iate, uue to a seveie seismic event, anu makes the social impact
of this event even biggei. Bospitals in co-oiuination with Civil Piotection
authoiities must guaiantee uninteiiupteu tiansfei passages (ioau tiails oi open
spaces foi helicopteis lanuing), in oiuei to achieve the fastest possible tiansfei
of those neeuing meuical caie(0BBS, 2u12).
S8K87 ;,+<6+@&?'+6 $,+$@ )", #$@.$5%&+@ >$'$?+>+'%

A catastiophic seismic event is possible to affect hospital facilities anu the neeu
foi the hospital to continue its opeiation without inteiiuption is ciitical.
Theiefoie, as it is iefeiieu in the pievious chaptei, it is impoitant, as a pait of the
uesign of hospital facilities, to incluue aieas, which can host all the meuical
opeiations in case of uigency. These aieas will iequiie the piopei equipment
anu assigneu staff to pioviue the piopei meuical seivices anu opeiate this
equipment. It is also neeueu these aieas to be pioviueu with eneigy anu watei,
that will make the opeiations of meuical caie moie effective.
S8K8K C@+ ") %,&$?+

As in any othei case of emeigency, the use of a tiiage system is neeueu,
especially in the chaotic conuition of a ciisis, to iuentify those with seiious anu
life-thieatening injuiies, in oiuei to pioviue them -immeuiately- the piopei
meuical caie. Statistics show that the numbei of minoi injuieu people is way
laigei than the seiiously injuieu anu that can cause a heavy tiaffic of people
seeking foi meuical caie. Foiwaiu tiiaging befoie people aie tiansfeiieu in
hospitals will help to iuentify those that aie in neeu of time-consuming meuical
caie anu it will pioviue a valuable amount of time foi the effective tieatment of
theii injuiies (uautschi et al, 2uu8).
S8K8S ;@D#*"5"?&#$5 @.11",%&=+ #$,+

The psychological effect in cases of catastiophic eaithquakes is something that
cannot be unueiestimateu. People with minoi injuiies go to hospitals just to be
ielieveu fiom woiiies anu get in touch with heavily injuieu people oi even ueau
people. In auuition, families of the heavily injuieu oi ueceaseu aie seeking foi
theii ielatives anu want to know what happeneu to them. The piesence of those
gioups of people can cieate a veiy uncomfoitable situation that may affect the
whole piocess of health caie. These people aie in neeu of counseling, which
shoulu piefeiably take place in an aiea away fiom the heating point of meuical
caie. It is also neeueu psychologists to be on site to pioviue to those injuieu
psychological counseling, as the shock of such a tiaumatic event has a significant
impact on theii health.



26
S8K8M ;,+1$,+6'+@@ E$@+6 "' @.,?+ @#&+'#+

Following a majoi seismic event, a laige numbei of patients is expecteu anu
hospitals neeu to ieoiganize theii opeiations anu manage theii iesouices to
pioviue sufficient health caie seivices. Baibisch et al. (2uu6) uesciibe a concept
of shifting ueployment of expeiienceu cooiuination expeits anu othei
specializeu humanitaiian peisonnel; know as the "SS System". The lettei -S-
stanus foi "staff, stuff anu stiuctuie". These thiee aie the key components that
neeu to be taken unuei consiueiation when hospitals uevelop theii emeigency
plans, anu help them to achieve a highei level of iesponsiveness uuiing a ciisis
inciuent. Befoie an emeigency occui, hospitals must be piepaieu with skilleu
anu tiaineu peisonnel, with enough meuical supplies, anu patient caie space
with inciuent management systems (Baibisch et al., 2uu6).

Regaiuing eaithquake inciuents, hospitals neeu to ensuie that they have
ielevant, anu in sufficient quantity, staff that is tiaineu to meuically manage the
uiffeient types of injuiies ielateu to the inciuent (buins, multi injuiies, injuiies
fiom gas pipe blasts etc.). As fai as it conceins the patient caie aieas, the
emeigency uepaitment shoulu be in a uiffeient place fiom that, which seives the
"woiiieu well". This can be achieveu with effective co-opeiation with
goveinmental authoiities.

In the following lists the vaiious factois that hospitals shoulu take unuei
consiueiation, iegaiuing the SS System, aie piesenteu.

2%$))

- Tiaining of meuical anu non-meuical peisonnel anu continuous testing anu
uevelopment of hospital's emeigency iesponse plan.
- Peisonnel with appiopiiate meuical knowleuge to manage casualties with
heavy injuiies anu combineu injuiies ielateu to the emeigent inciuent (buins,
multi-injuiies etc.)
- Availability of meuical peisonnel to pioviue seivices to the "woiiieu well" anu
offei psychological suppoit to injuieu people anu theii ielatives.

2%.))

- Availability of meuical iesouices foi theiapies against the meuical inciuents
that may occui
- Availability of items foi contamination contiols (wiaps, waste bins, flooi
coveiings)
- Availability of souices of eneigy anu watei that will enable the meuical caie of
patients.

2%,.#%.,+

- Besignation of uiffeient aieas foi those that aie heavily injuieu anu foi those
ueceaseu. Besignation of ioutes foi patient tianspoit in those aieas.
- Alteinate sites foi the tieatment of the "woiiieu well"
- Plan foi hanuling anu uisposal of the meuical waste to avoiu contaminations


27
3. Concluslons
Bospitals have as main mission to offei health seivices to the community, anu in
times of emeigency this mission becomes even moie impoitant. The piopei
function in eveiy pait of the hospital activity ensuies the continuity of health
seivices, anu in case of emeigency, that is a ciitical iole foi the quickest possible
iecoveiy fiom the potential ciisis, anu avoiuance of potential human losses.

Buiing emeigencies, the iole of hospitals is vital, because:

- They pioviue emeigency caie to injuieu anu ensuie that those in ciitical
conuition will iecovei
- They uelivei health caie befoie anu aftei the emeigent event
- They pioviue ciitical seivices, incluuing bloou banks, ambulances etc., that help
the community iecovei fiom a ciisis

Potential uisasteis in hospital facilities aie key blown in the noimal function of
the community, anu those makes the neeu foi the auaption of the stiictest
possible iules anu iegulation uuiing theii uesign anu builu piocess, emeigent. It
is also ciucial, foi hospitals to be able to ueal with eveiy possible ciisis that
might occui. That leaus to the foimation of oiganizeu inteinal piocesses that will
allow the noimal function of eveiy hospital activity, uuiing the case of an
emeigent event (e.g. an eaithquake).

If we look at the hospitals on theii whole as a complex system anu analyze them
with the Swiss Cheese mouel, the mouel will look like the one in the pictuie
below:



F&10-# YL 8B&++ ;"##+# '(<#2 )(- -&+6 %++#++'#/* &/ "(+,&*%2+

As we can see insufficient piemises uesign, ueficient tiaining piogiam of the
peisonnel, pooily uevelopeu iisk mitigation policies anu failuie in the
application of the uevelopeu uesign oi ciisis plan leau to the uysfunction of the
whole system, so the hospital is unable to meet its iole.


28
LlsL of 8eferences
1. 0S Bepaitment of Bomelanu Secuiity (2u12). Reuucing the Risks of
Nonstiuctuial Eaithquake Bamage-A Piactical uuiue, FENA E-74 Becembei
2u12

2. u. Bankoff, u. Fieiks, B. Bilhoist (eus.) (2uuS). Napping vulneiability:
Bisasteis, Bevelopment anu People.

S. "Eaithquake FAQ". Ciustal.ucsb.euu. Retiieveu 2u11-u7-24

4. Caiuona, 0.B. 2uu4. The neeu foi iethinking the concepts of vulneiability anu
iisk fiom a holistic peispective: a necessaiy ieview anu ciiticism foi effective
iisk management. In: Bankoff u., Fieiks u., Bilhoist B. (Eus.) Napping
vulneiability: uisasteis, uevelopment anu people.

S. 0' Banley, }. A. (1987). Eaithquake Risk Nitigation of Bospital Facilities: A Case
Stuuy of vancouvei ueneial Bospital

6. PN0B0K. (2uuS). A guiue to pioject management bouy of knowleuge (PNB0K
u0IBE) fouith euition. Wiley, N}.

7. 0S Bepaitment of Eneigy (B0E). 2uu2. Builuings foi the 21st Centuiy. 0ffice of
Builuing Technology, State anu Community Piogiams Newslettei. Washington,
BC. B0Eu0-1u2uu2-1S18. Wintei 2uu2.

8. Stamatis, B.B., Failuie Noue anu Effect Analysis: FNEA fiom Theoiy to
Execution. Ameiican Society foi Quality (ASQ), Nilwaukee, Wisconsin, 199S.

9. FENA (2uu7), Besign uuiue foi Impioving Bospital Safety in Eaithquakes,
Floous, anu Bigh Winus: Pioviuing Piotection to People anu Builuings, FENA
S77, Feueial Emeigency Nanagement Agency, Washington, BC, 0SA.

1u. Woilu Bealth 0iganization. 2uu6. Bealth Facility Seismic vulneiability
Evaluation. Woilu Bealth 0iganization Regional 0ffice of Euiope, Copenhagen,
Benmaik.

11. Eaithquake Planning & Piotection 0iganization. uieek Anti-seismic Builuing
Coue, Athens (2uu8)

12. ATC (2uuS), Recommenueu 0S-Italy collaboiative guiuelines foi biacing anu
anchoiing nonstiuctuial components in Italian hospitals, ATC-S1-2 Repoit,
Applieu Technology Council, Reuwoou City, Califoinia, 0SA.

1S. 0xfoiu Bictionaiy of English (S eu.) (2u12). 0xfoiu 0niveisity Piess



29
14. Callahan, R., B. N. Baveity anu R. Clayton (2uu8), 'Emeigency Nanagement
Netwoiks in Califoinia', in Piepaiing foi Bisasteis, Washington, B.C.: IBN Centei
foi the Business of uoveinment, pp.S7-S9

1S. Noynihan, B.P. (2uu7), Fiom Foiest Fiies to Buiiicane Katiina: Case Stuuies
of Inciuent Commanu Systems, Washington, B.C.: IBN Centei foi the Business of
uoveinment

16. Kaji, A.B., Koenig, K.L. anu Lewis, R.}. (2uu7) 'Cuiient hospital uisastei
piepaieuness', }ouinal of the Ameiican Neuical Association, vol. 298, No. 18,
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17. uautschi, 0.P., Cauosch, B., Rajan, u. anu Zellwegei, R. (2uu8, Naich-Apiil)
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Piehospital anu Bisastei Neuicine, vol. 2S, No. 2, pp.19S-2u1.

18. Baibisch BF, Koenig KL. 0nueistanuing suige capacity: essential elements.
Acau Emeig Neu. 2uu6;1S(11):1u98-1u2