Hospital organizational response to the nuclear accident at Three Mile Island: implications for future-oriented disaster planning

Difficulties faced by three hospitals evacuated from the urgent protective action planning zone after the 2011 Fukushima Daiichi Nuclear power plant accident

In radiological disasters, evacuating institutionalized individuals such as hospitalized patients and nursing home residents presents complex challenges. The Fukushima Daiichi Nuclear power plant (FDNPP) accident, triggered by the Great East Japan Earthquake (GEJE), exposed critical issues in evacuation planning. This case series investigates the evacuation difficulties encountered by three hospitals situated 20 to 30 km from the FDNPP following the GEJE and FDNPP accident. Data collection involved reviewing records, stakeholder interviews and analyzing publicly available resources. Six key challenges emerged: acute phase influx-hospitals faced an abrupt surge in patients, including trauma victims and vulnerable individuals; initial discharge and transfers-coordinating patient discharges and transfers during the chaotic aftermath proved daunting; staff shortages-evacuation and personal factors lead to reduced staffing levels and strained hospital capabilities; infrastructure damage and logistics suspension-infrastructure issues, such as burst water pipes, halted gas supplies, and heavy oil shortage disrupted hospital operations; unclear evacuation criteria-ad hoc evacuation decisions underscored the lack of clear criteria; and limited preparation time-minimal preparation time hindered communication and planning. These findings underscore the need for robust disaster planning, resource management, and communication strategies to ensure the safety of patients and staff during radiological emergencies. Government interventions, early patient discharge, and improved medical record communication may alleviate the burden of evacuation. The lessons learned emphasize the importance of maintaining hospital functions in disaster-prone areas, particularly for vulnerable populations, and highlight the necessity for comprehensive community-wide disaster prevention planning.

Emergency Hospital Evacuation From a Hospital Within 5 km Radius of Fukushima Daiichi Nuclear Power Plant: A Retrospective Analysis of Disaster Preparedness for Hospitalized Patients

Emergency evacuation during disasters may have significant health impacts on vulnerable populations. The Japanese Government issued evacuation orders for surrounding residents of the Fukushima Daiichi nuclear power plant (FDNPP) immediately after the March 11, 2011, nuclear accident. Little is known of difficulties associated with the disaster-specific evacuation from health care facilities located in this area. Among the 338 patients hospitalized at Futaba Hospital, located 4.6 km west of FDNPP, at the time of the accident, 39 patients (11.5%), predominantly critically ill patients who were bedridden or disabled, died before the evacuation was completed. The shortage of hospital staff and disruption of infrastructure resulted in a lack of adequate care provision, such as infusion therapy or sputum suctioning, leading to premature death of some hospitalized patients during the emergency hospital evacuation. As hospital evacuation is sometimes unavoidable during disasters, potential health impacts of hospital evacuation should be recognized and reflected in disaster preparedness plans.

Prevention and Control of COVID-19 in Imperfect Condition: Practical Guidelines for Nursing Homes by Japan Environment and Health Safety Organization (JEHSO)

Infection control at nursing homes is a top priority to address the COVID-19 pandemic because people who are the most vulnerable to the pathogen live in close contact. Currently, control measures specifically for nursing homes often ignore under-resourced condition of the facilities. To make guidelines assuming realistic conditions, an expert meeting with 16 members established the key challenges in nursing homes, the basics of infection control, and the major transmission routes. A list of existing guidance was compiled and each item in the list was peer-reviewed by eight experts considering three aspects: significance, scientific validity, and feasibility. Factors related to the nursing home environment, the nature of SARS-CoV-2 transmission, and patient characteristics were identified as the causes of difficulties in infection control at nursing homes. To develop realistic prevention measures in under-resourced condition such as nursing homes, we may need to accept there are no perfect control measures that can achieve zero risk. Instead, the guidelines are based on the concept of deep defense, and practical checklists with 75 items were established. The evaluation of nursing homes by independent organizations using the checklists would be helpful to achieve sustainable infection control.

Successful emergency evacuation from a hospital within a 5-km radius of Fukushima Daiichi Nuclear Power Plant: the importance of cooperation with an external body

Emergency evacuation during a disaster may have serious health implications in vulnerable populations. After the accident at the Fukushima Daiichi Nuclear Power Plant (FDNPP) in March 2011, the Japanese central government immediately issued an evacuation order for residents living near the plant. There is limited information on the process of evacuation from medical institutions within the evacuation zone and the challenges faced. This study collected and analyzed publicly available resources related to the Futaba Kosei Hospital, located 3.9 km northwest of the FDNPP, and reviewed the hospital's evacuation procedures. On the day of the accident at the FDNPP, 136 patients were admitted in the aforementioned hospital. The hospital's director received information about the situation at the FDNPP from the local disaster task force and requested the immediate evacuation of all patients. Consequently, four patients, including those with an end-stage condition, died during the evacuation. Early intervention by external organizations, such as the Japan Self-Defense Forces, helped the hospital to complete the evacuation without facing major issues. However, despite such an efficient evacuation, the death of four patients suggests that a significant burden is placed on vulnerable people during emergency hospital evacuations. Those with compromised health experience a heavy burden during a nuclear disaster. It is necessary for hospitals located close to a nuclear power plant to develop a more detailed evacuation plan by determining the methods of communication with external organizations that could provide support during evacuation to minimize the burden on vulnerable patients.

Evacuation after a nuclear accident: Critical reviews of past nuclear accidents and proposal for future planning

Standards and guidelines for preparedness and response in the case of a nuclear accident cover radiation protection, health management and communication with affected populations. Decision makers use these recommendations to decide on measures that protect people residing around a nuclear power plant that suffers an accident from radiation exposure; for example, sheltering, evacuation and relocation. While technological and radiological criteria exist for these protective measures, studies on past radiological and nuclear emergencies have shown that evacuation and relocation result in serious health effects; this needs to be considered in accident preparedness and responses in the future. Within the framework of the Nuclear Emergency Situations Improvement of Medical and Health Surveillance (SHAMISEN) (Ohba et al., 2020), a critical review of recommendations and experiences of previous major nuclear accidents was conducted, and the current paper focuses on the lessons learned about evacuation and relocation. We reviewed the contents of official documents and literature relating to the evacuation and relocation of residents, and to the evacuation of medical and other facilities in the three largest nuclear accidents to date: the Three Mile Island accident, Chernobyl accident, and Fukushima accident. We developed recommendations classified into the preparedness phase, early and intermediate phases, and recovery phase after an accident. In the cases of Three Mile Island and Fukushima, the evacuation area was set at 8-10 km from the nuclear power plant in the disaster prevention plan, and emergency responses, such as information provision and evacuation, had been developed only in this area. When the Fukushima accident occurred, evacuation beyond this area was urgently planned or instructed, resulting in marked confusion, such as forced multiple evacuations and relocations for long periods. Furthermore, information was lacking, and personal protective measures such as respiratory protection and iodine prophylaxis were not applied to evacuees. In hospital and facility evacuation, it became more difficult to implement evacuation owing to a lack of advance planning and support in the event of the accident. In Fukushima, more than 60 people in hospitals and nursing care facilities died during or soon after evacuation. In long-term relocation, in addition to continuing adverse mental effects, there were health effects relating to relocation, such as lifestyle-related disease. The return of residents to the evacuation area required many issues, such as a delayed recovery of the living environment, to be overcome in addition to measures to reduce the effects of radiation. Recommendations for evacuation in the SHAMISEN framework were developed (SHAMISEN Consortium, 2017; Liutsko et al., 2020) from these lessons of previous accidents.

Emergency Department Response to Chemical, Biological, Radiological, Nuclear, and Explosive Events: A Systematic Review

Introduction

A Chemical, Biological, Radiological, Nuclear, and explosive (CBRNe) event is an emergency which can result in injury, illness, or loss of life. The emergency department (ED) as a health system is at the forefront of the CBRNe response with staff acting as first receivers. Emergency departments are under-prepared to respond to CBRNe events - recognizing key factors which underlie the ED CBRNe response is crucial to provide evidence-based knowledge to inform policies and, most importantly, clinical practice.

Problem

Challenges in detection, decontamination, and diagnosis are associated with the ED CBRNe response when faced with self-presenting patients.

Methods

A systematic review was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). An in-depth search strategy was devised to identify studies which focused on the ED and CBRNe events. The inclusion criteria were stringent in terms of the environment (ED), participants (first receivers), situation (CBRNe response), and actions (detection, decontamination, and diagnosis). Fifteen databases and topic-specific journals were searched. Studies were critically appraised using the Mixed Methods Appraisal Tool (MMAT). Papers were thematically coded and synthesized using NVivo 10 (QSR International Ltd, Melbourne, Australia).

Results

Sixty-seven full-text papers were critically appraised using the MMAT; 70% were included (n = 60) as medium- or high-quality studies. Data were grouped into four themes: preparedness, response, decontamination, and personal protective equipment (PPE) problems.

Discussion

This study has recognized the ED as a system which depends on four key factors - preparedness, response, decontamination, and PPE problems - which highlight challenges, uncertainties, inconsistencies, and obstacles associated with the ED CBRNe response. This review suggests that response planning and preparation should be considered at three levels: organizational (policies and procedures); technological (decontamination, communication, security, clinical care, and treatment); and individual (willingness to respond, PPE, knowledge, and competence). Finally, this study highlighted that there was a void specific to detection and diagnosis of CBRNe exposure on self-presenting patients in the ED.

Conclusion:

The review identified concerns for both knowledge and behaviors which suggests that a systems approach would help understand the ED response to CBRNe events more effectively. The four themes provide an evidence-based summary for the state of science in ED CBRNe response, which can be used to inform future policies and clinical procedures.

RazakS,HignettS,BarnesJ.Emergency department response to chemical, biological, radiological, nuclear, and explosive events: a systematic review.Prehosp Disaster Med.2018;33(5):543–549.

PKCδ inhibition as a novel medical countermeasure for radiation-induced vascular damage

In the event of a radiologic catastrophe, endothelial cell and neutrophil dysfunction play important roles in tissue injury. Clinically available therapeutics for radiation-induced vascular injury are largely supportive. PKCδ was identified as a critical regulator of the inflammatory response, and its inhibition was shown to protect critical organs during sepsis. We used a novel biomimetic microfluidic assay (bMFA) to interrogate the role of PKCδ in radiation-induced neutrophil-endothelial cell interaction and endothelial cell function. HUVECs formed a complete lumen in bMFA and were treated with 0.5, 2, or 5 Gy ionizing radiation (IR). At 24 h post-IR, the cells were treated with a PKCδ inhibitor for an additional 24 h. Under physiologic shear flow, the role of PKCδ on endothelium function and neutrophil adherence/migration was determined. PKCδ inhibition dramatically attenuated IR-induced endothelium permeability increase and significantly decreased neutrophil migration across IR-treated endothelial cells. Moreover, neutrophil adhesion to irradiated endothelial cells was significantly decreased after PKCδ inhibition in a flow-dependent manner. PKCδ inhibition downregulated IR-induced P-selectin, intercellular adhesion molecule 1, and VCAM-1 but not E-selectin overexpression. PKCδ is an important regulator of neutrophil-endothelial cell interaction post-IR, and its inhibition can serve as a potential radiation medical countermeasure.-Soroush, F., Tang, Y., Zaidi, H. M., Sheffield, J. B., Kilpatrick, L. E., Kiani, M. F. PKCδ inhibition as a novel medical countermeasure for radiation-induced vascular damage.

Long-term outcomes of patients evacuated from hospitals near the Fukushima Daiichi nuclear power plant after the Great East Japan Earthquake

Introduction

After the accident of the Fukushima Daiichi nuclear power plant due to the Great East Japan Earthquake in March 2011, the Japanese government issued a mandatory evacuation order for people living within a 20 km radius of the nuclear power plant. The aim of the current study was to investigate long-term outcomes of these patients and identify factors related to mortality.

Materials and methods

Patients who were evacuated from hospitals near the Fukushima Daiichi nuclear power plant to the Aizu Chuo Hospital from 15 to 26 March, 2011 were included in this study. The following data were collected from medical records: age, sex, activities of daily life, hospital they were admitted in at the time of earthquake, distance between the facility and the nuclear power plant, reasons of evacuation and number of transfers. The patient outcomes were collected from medical records and/or investigated on the telephone in January 2012.

Results

A total of 97 patients (28 men and 69 women) were transferred from 10 hospitals via ambulances or buses. No patients died or experienced exacerbation during transfer. Median age of the patients was 86 years. Of the total, 36 patients were not able to obey commands, 44 were bed-ridden and 61 were unable to sustain themselves via oral intake of food. Among 86 patients who were followed-up, 41 (48%) died at the end of 2011. Multiple-regression analysis showed that non-oral intake [Hazard Ratio (HR): 6.07, 95% Confidence interval (CI): 1.94–19.0] and male sex [HR: 8.35, 95% CI: 2.14–32.5] had significant impact on mortality.

Conclusion

This study found that 48% of the evacuated patients died 9 months after the earthquake and they had significantly higher mortality rate than the nursing home residents. Non-oral intake and male sex had significant impact on mortality. These patients should be considered as especially vulnerable in case of hospital evacuation.

Disappearing everyday materials: The displacement of medical resources following disaster in Fukushima, Japan

This study draws upon interviews of medical staff working in the city of Minamisoma, Japan, following the 2011 Triple Disaster. It investigates staff responses to the disruption of material resources as a consequence of the disaster and its management. The disruption of spaces, and the loss of oxygen supplies, food, and medications impacted upon staff experience and the ability of institutions to care for patients. This resulted in a restructuring of spaces and materials as workers made efforts to reconfigure and reestablish healthcare functions. This is one of the few qualitative studies which draws upon the experience and perspectives of health workers in understanding material disruption following disaster. This is particularly important since this case did not involve the breakdown of lifeline infrastructure, but rather, brought to attention the way everyday material objects shape social experience. In highlighting these effects, the paper makes the case for the social scientific investigation of the impact of disasters on healthcare, shedding light on an area of research currently dominated by disaster medicine.

Hospital Staff Shortage after the 2011 Triple Disaster in Fukushima, Japan-An Earthquake, Tsunamis, and Nuclear Power Plant Accident: A Case of the Soso District

Introduction

In 2011, Fukushima was struck by a triple disaster: an earthquake, tsunamis, and a nuclear accident. In the aftermath, there was much fear among hospital staff members about radiation exposure and many staff members failed to report to work.

Objectives

One objective is to measure this shortage in hospital staff and another is to compare the difference in recovery by hospital types and by categories of hospital staff.

Design

The monthly records of the number of staff members from May 2011 to September 2012 were extracted anonymously from the records of 7 local hospitals in the Soso district in Fukushima. Change in the number of staff was analyzed.

Results

Staff shortages at hospitals reached a maximum within one month after the disaster (47% reported to work). The shortage of clerks was the most severe (38% reported to work), followed by nurses (48% reported to work). The shortages remained even 18 months after the disaster.

Conclusion

After a disaster in which the damage to hospital functions surpasses the structural damage, massive support of human resources in the acute phase and a smaller volume of support in the mid-term phase appear to be required, particularly for non-medical staff.

Impacts of the 2011 Fukushima nuclear accident on emergency medical service times in Soma District, Japan: a retrospective observational study

OBJECTIVE

To assess the influence of the 3.11 triple disaster (earthquake, tsunami and nuclear accident) on the emergency medical service (EMS) system in Fukushima.

METHODS

Total EMS time (from EMS call to arrival at a hospital) was assessed in the EMS system of Soma district, located 10-40 km north of the nuclear plant, from 11 March to 31 December 2011. We defined the affected period as when total EMS time was significantly extended after the disasters compared with the historical control data from 1 January 2009 to 10 March 2011. To identify risk factors associated with the extension of total EMS time after the disasters, we investigated trends in 3 time segments of total EMS time; response time, defined as time from an EMS call to arrival at the location, on-scene time, defined as time from arrival at the location to departure, and transport time, defined as time from departure from the location to arrival at a hospital.

RESULTS

For the affected period from week 0 to week 11, the median total EMS time was 36 (IQR 27-52) minutes, while that in the predisaster control period was 31 (IQR 24-40) min. The percentage of transports exceeding 60 min in total EMS time increased from 8.2% (584/7087) in the control period to 22.2% (151/679) in the affected period. Among the 3 time segments, there was the most change in transport time (standardised mean difference: 0.41 vs 0.13-0.17).

CONCLUSIONS

EMS transport was significantly delayed for ∼3 months, from week 1 to 11 after the 3.11 triple disaster. This delay may be attributed to malfunctioning emergency hospitals after the triple disaster.

The nuclear disaster management system in Taiwan: a case study of the third (Maanshan) nuclear power plant

This paper explores the effectiveness of the nuclear disaster management system in Taiwan via a review of the third (Maanshan) nuclear power plant. In doing so, the Fukushima Daiichi nuclear disaster in Japan on 11 March 2011 is reviewed and compared with the situation in Taiwan. The latter's nuclear disaster management system is examined with respect to three key variables: information; mobilisation; and inter-organisational cooperation. In-depth interviews with 10 policy stakeholders with different backgrounds serve as the research method. The results point up the need for improvement in all dimensions. In addition, they highlight three principal problems with the nuclear disaster management system: (i) it might not be possible to provide first-hand nuclear disaster information immediately to the communities surrounding the Maanshan facility in Pingtung County, southern Taiwan; (ii) the availability of medical resources for treating radiation in Hengchun Township is limited; and (iii) the inter-organisational relationships for addressing nuclear disasters need to be strengthened. Hence, cooperation among related organisations is necessary.

Health effects of radiation and other health problems in the aftermath of nuclear accidents, with an emphasis on Fukushima

437 nuclear power plants are in operation at present around the world to meet increasing energy demands. Unfortunately, five major nuclear accidents have occurred in the past--ie, at Kyshtym (Russia [then USSR], 1957), Windscale Piles (UK, 1957), Three Mile Island (USA, 1979), Chernobyl (Ukraine [then USSR], 1986), and Fukushima (Japan, 2011). The effects of these accidents on individuals and societies are diverse and enduring. Accumulated evidence about radiation health effects on atomic bomb survivors and other radiation-exposed people has formed the basis for national and international regulations about radiation protection. However, past experiences suggest that common issues were not necessarily physical health problems directly attributable to radiation exposure, but rather psychological and social effects. Additionally, evacuation and long-term displacement created severe health-care problems for the most vulnerable people, such as hospital inpatients and elderly people.

Nuclear disasters and health: lessons learned, challenges, and proposals

Past nuclear disasters, such as the atomic bombings in 1945 and major accidents at nuclear power plants, have highlighted similarities in potential public health effects of radiation in both circumstances, including health issues unrelated to radiation exposure. Although the rarity of nuclear disasters limits opportunities to undertake rigorous research of evidence-based interventions and strategies, identification of lessons learned and development of an effective plan to protect the public, minimise negative effects, and protect emergency workers from exposure to high-dose radiation is important. Additionally, research is needed to help decision makers to avoid premature deaths among patients already in hospitals and other vulnerable groups during evacuation. Since nuclear disasters can affect hundreds of thousands of people, a substantial number of people are at risk of physical and mental harm in each disaster. During the recovery period after a nuclear disaster, physicians might need to screen for psychological burdens and provide general physical and mental health care for many affected residents who might experience long-term displacement. Reliable communication of personalised risks has emerged as a challenge for health-care professionals beyond the need to explain radiation protection. To overcome difficulties of risk communication and provide decision aids to protect workers, vulnerable people, and residents after a nuclear disaster, physicians should receive training in nuclear disaster response. This training should include evidence-based interventions, support decisions to balance potential harms and benefits, and take account of scientific uncertainty in provision of community health care. An open and joint learning process is essential to prepare for, and minimise the effects of, future nuclear disasters.

Impact of Natural Disaster Combined with Nuclear Power Plant Accidents on Local Medical Services: a Case Study of Minamisoma Municipal General Hospital after the Great East Japan Earthquake

Objective

To elucidate the impacts of nuclear plant accidents on neighboring medical centers, we investigated the operations of our hospital within the first 10 days of the Great East Japan Earthquake followed by the Fukushima Daiichi nuclear power plant accident.

Methods

Data were extracted from medical records and hospital administrative records covering 11 to 20 March 2011. Factual information on the disaster was obtained from public access media.

Results

A total of 622 outpatients and 241 inpatients were treated. Outpatients included 43 injured, 6 with cardiopulmonary arrest, and 573 with chronic diseases. Among the 241 inpatients, 5 died, 137 were discharged, and the other 99 were transferred to other hospitals. No communication methods or medical or food supplies were available for 4 days after the earthquake. Hospital directors allowed employees to leave the hospital on day 4. All 39 temporary workers were evacuated immediately, and 71 of 239 full-time employees remained. These employees handled extra tasks besides patient care and patient transfer to other hospitals. Committed effective doses indicating the magnitude of health risks due to an intake of radioactive cesium into the human body were found to be minimal according to internal radiation exposure screening carried out from July to August 2011.

Conclusions

After the disaster, hospitals located within the evacuation zone of a 30-km radius of the nuclear power plant were isolated. Maintenance of the health care system in such an event becomes difficult. (Disaster Med Public Health Preparedness. 2014;8:471-476)

Benchmarking for Hospital Evacuation: A Critical Data Collection Tool

In events such as earthquakes or terrorist attacks, hospitals may be victims of disasters. They may need to transfer patients to outside facilities rather than continue to provide on-site care. Following the Northridge earthquake, eight hospitals in the damaged area were the foci of a United States National Science Foundation study that examined the status of the hospitals' pre-event planning, post-event evacuationdecision-making, and internal and external evacuation processes. Building on this experience, this paper offers a standardized data collection tool, which will enable researchers to record hospital evacuation information in a systematic manner so that comparable data can be accumulated, evacuation research methods can be improved, and consensus on methods can be reached. The study's principal subjects include: (1) hospital demographics; (2) description of existing disaster response plans; (3) an event's impacts on hospital operations; (4) decision-making and incident command; (5) movement of patients within the facility; (6) movement of patients to off-site institutions; and (7) hospital recovery.

Evacuation and Sheltering of Hospitals in Emergencies: A Review of International Experience

Objective:

A scoping exercise to establish how common hospital evacuations are, identify hospital evacuation policies and review case studies to identify trig-gers, processes and challenges involved in the evacuation of hospitals globally.

Design:

A systematic search of PubMed and disaster agency online resources, search of grey literature and media reports.

Results:

This study showed that hospitals are vulnerable to both natural and man made disasters and that hospital evacuations do occur globally. It highlighted the paucity of published data and policy on hospital evacuation and emphasised the vital need to collect data on triggers, reasons for evacuation, sheltering facilities and the process of evacuation.

Conclusions:

This study recommends the collection of case studies and the development of a database to assist with the research and development of well tailored hospital evacuation plans. These recommendations reflect and support the 2008-2009 World Disaster Reduction Campaign on Hospitals Safe from Disasters and the timely 2009 Global Platform priority that, ‘Critical services and infrastructure such as health facilities and schools must be safe from disasters.

The importance of evidence-based disaster planning

Disaster planning is only as good as the assumptions on which it is based. However, some of these assumptions are derived from a conventional wisdom that is at variance with empirical field disaster research studies. Knowledge of disaster research findings might help planners avoid common disaster management pitfalls, thereby improving disaster response planning. To illustrate the point, this article examines several common assumptions about disasters, compares them with research findings, and discusses the implications for planning. These assumptions are that: 1. Dispatchers will hear of the disaster and send emergency response units to the scene. 2. Trained emergency personnel will carry out field search and rescue. 3. Trained emergency medical services personnel will carry out triage, provide first aid or stabilizing medical care, and--if necessary--decontaminate casualties before patient transport. 4. Casualties will be transported to hospitals by ambulance. 5. Casualties will be transported to hospitals appropriate for their needs and in such a manner that no hospitals receive a disproportionate number. 6. Authorities at the scene will ensure that area hospitals are promptly notified of the disaster and the numbers, types, and severities of casualties to be transported to them. 7. The most serious casualties will be the first to be transported to hospitals. The current status and limitations of disaster research are discussed, and potential interventions to response problems are offered that may be of help to planners and practitioners and that may serve as hypotheses for future research.

Emergency medicine and the developing world

The developing countries of the world represent a new environment in which to apply the unique expertise and knowledge of emergency medicine. With an understanding of the cultural, political and economic forces that affect health care in developing countries, American emergency physicians should consider collaboration with their counterparts in developing countries in such areas as prehospital care systems, trauma care, disaster management, poison information and management systems, and education related to clinical services, administration, and research methods in emergency medicine. Such collaboration can broaden the field of emergency medicine and fulfill individual humanitarian goals.