Canadian Coalition for Green Health Care Facility Climate Change Resiliency Toolkit Facilitator Presentation Canadian Coalition for Green Health Care

Contents How facilitators can use this presentation Benefits of assessing health care facility resiliency to climate change Introduction to climate change impacts on health care facilities (in Nova Scotia) Completing the health care facility resiliency assessment checklist

How facilitators can use this presentation Conduct the assessment by following instructions outlined in this presentation. Use this presentation to facilitate the assessment discussion. Engage health care facility officials by tailoring this presentation to your needs. Administer the assessment checklist at a meeting, workshop, or through direct mail-out. Use the notes pages and comments sections in the tool to capture information and data. It is recommended that the facilitator(s) invite senior level officials (e.g. directors, managers) to participate in reviewing and completing this tool. Individuals who work in the following areas may be best suited to participate: Emergency Management Human Resources Occupational Health and Safety Pharmaceuticals, Medications and Vaccines Nutrition and food services Public Health Green Team Director / Manager Environmental waste management Facilities and maintenance Logistical services (managing supply flow in) Waste management (managing waste flow out) Supplies and purchasing Clinical services Housekeeping and laundering Green team / sustainability

Benefits of assessing climate resiliency Health care facilities are vital assets to communities on a day-to-day basis and when disaster strikes. Safe hospitals protect patients, visitors staff and the investment in health infrastructure from hazards. Safe hospitals continue to function and provide life-saving medical care in disasters. Assessment of the safety and preparedness of hospitals identifies priorities for remedial action, including cost-effective retrofitting. New hospitals are safeguarded by risk-sensitive siting, design and building in compliance with building codes. Emergency planning, staff training and exercises build hospital capacity to manage risks and respond effectively. WHO, 2011 World Health Organization (WHO), 2011. Disaster Risk Management for Health – Safe Hospitals: Prepared for Emergencies and Disasters. Available at: http://www.who.int/hac/events/drm_fact_sheet_safe_hospitals.pdf

Benefits of assessing climate resiliency Helps identify and better characterize vulnerabilities and risk levels at your health care facility and provides a data baseline. Helps stimulate actions to increase the capacity of health care facility staff for climate change impacts, many of which are occurring now. Identifies key officials and institutional linkages - mobilizes health care facility staff and community partners to work on shared goals. Improves health care facility climate awareness and preparedness Supports evidence informed decision-making to reduce health risks from climate change.

Health risks in Canada from climate change Dangerous travelling conditions Permafrost melt damaging infrastructures Changes in drinking water quality and quantity Food security - changing animal distributions Heat–related illnesses and deaths Health impacts from more severe storms Climate Change and Health in Canada The phenomenon of human-induced global climate change can no longer be refuted. According to the 2007 report of the Intergovernmental Panel on Climate Change (IPCC): “Warming of the climate system is unequivocal, as is now evident from observations of increases in global average air and ocean temperatures, widespread melting of snow and ice and rising global average sea level.” One of the most disturbing implications of climate change is its potentially devastating impact on human health. The World Health Organization (WHO) has reported: “A warmer and more variable climate threatens to lead to higher levels of some air pollutants, increase transmission of diseases through unclean water and through contaminated food, to compromise agricultural production in some of the least developed countries, and increase the hazards of extreme weather… Temperature shifts will encourage the spread of infectious diseases… An increase in extreme weather events like floods and droughts will have a dramatic impact on health.” A national climate change and health vulnerability assessment was released in 2008 by Health Canada entitled Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity . In the report, it provides information on how climate change may impact the health of Canadians across the country. To obtain a copy of this report, please refer to the following website: http://www.hc-sc.gc.ca/ewh-semt/climat/eval/index-eng.php) Psychosocial impacts from droughts Water-borne diseases from floods Expansion of Lyme Disease vector Respiratory illnesses from forest fires Source: Health Canada, 2008

Health risks in Canada from climate change The frequency of weather related disasters in Canada is increasing as evidenced by information obtained from the Canadian Disaster Database. The graph in this slide presents data on the number of extreme weather events that occurred in the 20th century and the first decade of the 21st century. Data was tabulated using information from Public Safety Canada’s Canadian Disaster Database. The frequency and intensity of different types of extreme weather events have varied across Canada. For further information about the natural disasters that have affected Canada in this time period, please refer to Public Safety Canada’s Canadian Disaster Database available at: http://www.publicsafety.gc.ca/prg/em/cdd/index-eng.aspx Weather- related Disasters in Canada (1900-2011) Canadian Disaster Database, 2012

Health risks in Canada from climate change This graph presents data on the historical and projected number of hot days and warm nights for selected cities in Canada. Projections are provided for the time periods:2011-2040, 2041-2070 and 2071-2100. The figures indicate that cities will become increasingly warmer in the coming decades. This has important implications for health of people in these communities, especially those that are most vulnerable to extreme temperatures (e.g. elderly, infants and children, persons with chronic diseases, persons on some medications and those that are active outdoors). Historical and projected number of hot days and warm nights for selected cities in Canada Health Canada, 2012

Climate change impacts on health in Nova Scotia Climate change is a health issue in Nova Scotia Risks to health from climate change are increasing because of increases in severity and frequency of extreme weather events, expansion of vector-borne diseases and increases in food and water borne contamination Some impacts are already being observed - Since the first cases reported in 2002, the annual number of reported cases of Lyme disease in Nova Scotia has been increasing Increased climate variability are expected to put more pressures on health care facilities and threaten patient, staff and visitor safety Health care facility resiliency assessments can provide information to raise awareness of health risks and direct actions to help people at risk

Climate change impacts on health in Nova Scotia This figure includes risk maps for the establishment and spread of the Lyme disease vector Ixodes scapularis under current climate (2000) and projected future climate (2020 to 2080) in Eastern Canada. Reference: Ogden N., Laurie St-Onge, Ian K Barker, Stéphanie Brazeau, Michel Bigras-Poulin, Dominique F Charron, Charles M Francis, Audrey Heagy, L Robbin Lindsay, Abdel Maarouf, Pascal Michel, François Milord, Christopher J O'Callaghan, Louise Trudel, and R Alex Thompson (2008). Risk maps for range expansion of the Lyme disease vector, Ixodes scapularis, in Canada now and with climate change. International Journal of Health Geographics, 7(24) pp 1-15. Accessible at: http://www.biomedcentral.com/content/pdf/1476-072x-7-24.pdf Risk maps for the establishment and spread of the Lyme disease vector Ixodes scapularis under current climate (2000) and projected future climate (2020 to 2080) (Ogden et al. 2008).

Climate change in Canada: Resources Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity (Health Canada, 2008) http://www.hc-sc.gc.ca/ewh-semt/climat/eval/index-eng.php From Impacts to Adaptation: Canada in a Changing Climate 2007 (Natural Resources Canada, 2008) http://www.nrcan.gc.ca/earth-sciences/climate-change/community-adaptation/assessments/132 Update: From Impacts to Adaptation: Canada in a Changing Climate (Natural Resources Canada, available in 2013) Health care facility officials in Canada can use the references presented on this slide to learn about how climate change is expected to affect their region.

Climate-related impacts to health care facilities: examples Extreme storms Ice-storms Hurricanes Water-borne contamination Heat-waves Described below are examples of climate related events and how they impacted health care facilities. Examples are provided according to the type of climate related event. 1 - ICE STORM Eastern Ontario and Southwest Quebec, January 1998   In January of 1998, Eastern Ontario and Southwest Quebec endured five days of freezing rain. The weight of the ice on hydro towers and trees caused substantial damage; large areas lost power, some for three weeks; roadways were blocked with fallen trees and ice, blocking access to patients in need and hospitals (Hamilton, 1998). Hospitals reported a spike in injuries (e.g., broken bones, head injuries from falling), cardiac problems, carbon monoxide poisoning and breathing problems. The cardiac problems could be attributed to physical labour (e.g., clearing ice). They could also have been due to insufficient medication for displaced cardiac patients – patient files stored on computers were inaccessible due to power loss. People using dangerous methods to create warmth (e.g., using a BBQ indoors, running a car while asleep) and/or ventilation systems being shut down to conserve power may have lead to hundreds of cases of carbon monoxide poisoning – 45 patients were treated with Montreal’s hyperbaric chamber within the first nine days. In the weeks to come, there was a spike in breathing problems (i.e., emphysema, bronchitis, asthma) likely due to living in cold homes and/or poor ventilation (Hamilton, 1998). Hospitals lost power but also had to act as shelter to staff, patients and residents. They were also used as a place to support patients requiring power for their respirators, discharged patients without a safe home or to supply food to a nearby long-term care facility. Hospitals in Montreal had the additional challenge of boiling water and putting signs on all of their sinks prohibiting the use of the water, due to the city’s water treatments plants losing power. Three emergency shelters in Montreal experienced an outbreak of influenza A. An Ontario hospital in a small town felt very isolated, a feeling exacerbated when they could not use their phones. Staff found that they needed to look after the health and psychosocial needs of those in hospitals and shelters in these challenging conditions, something that was not part of any emergency plan. Some residents and emergency workers started to show signs of post-traumatic stress (Hamilton, 1998). Reference: Hamilton J. (1998). Quebec's ice storm '98: "all cards wild, all rules broken" in Quebec's shell-shocked hospitals. CMAJ, 158(4):520-5. 2 - HURRICANE Hurricane Sandy, Eastern United States, 2013 NEW YORK (AP) — A backup generator failed at a New York City hospital Monday night, forcing it to move out more than 200 patients, including 20 babies from neonatal intensive care. Dozens of ambulances lined up around the block outside New York University Tisch Hospital as doctors and nurses began the slow process of evacuation. They started with the sickest and youngest. Some were on respirators operating on battery power. "It's a challenging situation," NYU Medical Dean Robert Grossman told WCBS-TV. "We drill all the time for this kind of thing. But this isn't a drill. This is the real thing." Much of New York was plunged into darkness by superstorm Sandy, a monstrous hybrid system that swept across a huge swath of the East. Most of the power outages in lower Manhattan, where Tisch is located, were due to an explosion at an electrical substation, officials at Consolidated Edison said. It wasn't clear whether flooding or flying debris caused the explosion, said John Miksad, senior vice president for electric operations at Con Edison. Without power, there are no elevators, meaning patients — some of whom are being treated for cancer and other serious illnesses — must be carefully carried down staircases, Grossman said. As the patients were evacuated, gusts of wind blew their blankets. Nurses and staff huddled around the patients, some holding IVs and other equipment. Ambulances came from around the city to help transport the sick. Patients will be taken to other hospitals including Mount Sinai and the Memorial Sloan-Kettering Cancer. Reference: http://bigstory.ap.org/article/power-out-nyc-hospital-200-patients-evacuated Other References: http://www.thestar.com/news/world/article/1279495--hurricane-sandy-babies-among-more-than-200-patients-evacuated-as-hospital-loses-power http://abcnews.go.com/blogs/headlines/2012/10/mount-sinai-steps-in-for-hospitals-overwhelmed-by-sandy/ http://www.myhealthnewsdaily.com/3229-hospital-power-outages-hurricane-sandy.html http://www.geron.org/About%20Us/press-room/Archived%20Press%20Releases/80-2012-press-releases/1387-seniors-particularly-vulnerable-in-sandys-aftermath http://www.nj.com/news/index.ssf/2012/11/sandys_aftermath_leaves_nj_res.html http://www.propublica.org/article/nyus-backup-system-undone-by-key-part-in-flooded-basement http://www.nejm.org/doi/full/10.1056/NEJMp1213486 http://www.nejm.org/doi/full/10.1056/NEJMp1213843 3 - WATER-BORNE CONTAMINATION Walkerton, Ontario 2000 Thousands of people became ill from drinking water contaminated with E. coli bacteria; seven people died. For over five days, residents were being told that the water was safe to drink, creating more illness. Hospitals reported a sudden spike in patients with bloody diarrhea and vomiting (CBC News, 2010). Waiting times extended into hours, with patients told to drink more water, prior to water being identified as the source, to prevent dehydration (Dunn, 2010). Dozens were hospitalized, staying an average of two weeks (Livernois, 2001). Some really ill patients had to be transferred to other hospitals for surgeries (Dunn, 2010; Livernois, 2001). Years following the Crisis, some residents live with chronic medical (e.g., renal disease, diabetes) and mental (e.g., post-traumatic stress, brain damage) conditions (Dunn, 2010). References: CBC News. May 17, 2010. Obtained online December 3, 2012 from http://www.cbc.ca/news/canada/story/2010/05/10/f-walkerton-water-ecoli.html.; Dunn, Scott. May 19, 2010. Kody Hammell’s ongoing triumph. Sun Times. Obtained online December 3, 2012 from http://suntimeswalkerton.wordpress.com/ ; Livernois J. (2001). The Walkerton Inquiry Commissioned Paper 14: The Economic Costs of the Walkerton Water Crisis. Obtained online December 3, 2012 from http://www.uoguelph.ca/~live/Livernois_14%20Final%20Report.pdf 4 – HEAT WAVE Europe, 2010 During the summer of July 2010, most of Europe and European Russia experienced a major heat wave. The whole summer was the hottest in 500 years with recorded temperatures five to ten degrees higher than normal (Carrington, 2011; AP, 2010). There were tens of thousands of deaths resulting from heatstroke and respiratory problems. Crops were lost, increasing the cost of food; forest fires occurred; roads melted (Carrington, 2011; AP, 2010). In Moscow, the morgues were filled to capacity (Carrington, 2011). In Germany, air conditioning systems breaking down in trains sent forty passengers to hospitals with dehydration and heat exhaustion (Spiegel Online International, 2010). Water was in short supply in Russia (The Telegraph, 2011). Other areas had excessive rain fall; in Switzerland, the large rain fall combined with melting glacier triggered avalanches and flash floods (Wikipedia). These distinct heat-related events can all produce problems for hospitals: blocked access to hospitals and those in need, challenges obtaining food and water, and quickly exceeding capacity in hospitals. References: AP. Jul 17, 2010. Crops wither, roads melt in European heat wave. Taipei Times. Obtained online December 4, 2012 from http://www.taipeitimes.com/News/world/archives/2010/07/17/2003478114 Carrington D. 17 March 2011. Deadly heatwaves will be more frequent in coming decades, say scientists. The Guardian. Obtained online December 4, 2012 from http://www.guardian.co.uk/environment/2011/mar/17/deadly-heatwaves-europe Spiegel Online International. July 12, 2010. Heatwave Grips Europe: Germany Swelters Amid Soaring Temperatures. Spiegel Online. Obtained online December 4, 2012 from http://www.spiegel.de/international/europe/heatwave-grips-europe-germany-swelters-amid-soaring-temperatures-a-705963.html The Telegraph. July 22, 2011. Worst heatwaves in history: timeline. Telegraph Media Group Limited. Obtained online December 4, 2012 from http://www.telegraph.co.uk/news/worldnews/northamerica/usa/8653974/Worst-heatwaves-in-history-timeline.html Wikipedia. 2010 Northern Hemisphere summer. Obtained online December 4, 2012 from http://en.wikipedia.org/wiki/2010_Northern_Hemisphere_summer 5 – POWER OUTAGE North American Power Outage, 2002 For over 24 hours, eight US states and parts of a province in Canada (Ontario) were without power following a power grid failure. Two large US cities (Detroit and Cleveland) issued a water use ban following a loss of water pressure. Hospitals encountered a range of problems, including infrastructure (e.g., lighting, elevators, heating, air conditioning, ventilation, isolation facilities, toilets, kitchen), supply (e.g., water, food, pharmaceuticals, paper, fuel for generators), failure of technology (e.g., computers, internet access, patient registration, communication, cell phone reception, emergency power, transportation, radiology equipment, refrigerators), sanitation and staffing (e.g., out-of-date contact list; Klein et al., 2005). Reference: Klein KR, Rosenthal MS, Klausner HA. (2005). Blackout 2003: preparedness and lessons learned from the perspectives of four hospitals. Prehosp Disaster Med. 20(5):343-9.

Hurricane Juan, 2003 A category 2 hurricane made landfall in Nova Scotia as one of the most damaging hurricanes in Canada. It was responsible for eight deaths More than 300,000 people were without power for up to 10 days Telephone service was disrupted and the water infrastructure was compromised Hospital infrastructure was damaged (e.g. roof damage, flooding and water damage, patient evacuations, limited beds, compromised resources) Hurricane Juan, 2003   “In September 2003, Hurricane Juan, a category 2 hurricane, made landfall in Nova Scotia as one of the most powerful and damaging hurricanes ever to affect Canada. Juan was responsible for eight deaths.2 More than 300,000 people were without power for up to 10 days, telephone service was disrupted and the water infrastructure was compromised Major hospitals were affected by the devastation, including the Victoria General Hospital in Halifax. With part of its roof ripped off, the hospital sustained flooding and water damage to eight floors, including storage rooms that contained sterile medical supplies. More than 200 patients had to be relocated to other facilities. Beds at functioning facilities became scarce, as most patients, even those with minor injuries, could not be sent home since the essential resources needed to manage their own care (power, water and telephone) were compromised. The impacts of Juan were felt for up to four weeks after the event. For example, owing to flooding and air quality issues related to the presence of possible moulds, the Victoria General did not open its operating theatres until four weeks after the initial event. The resulting cancellation of 78% of scheduled surgeries increased surgical wait lists as the 370 cancelled surgeries were rebooked. Many lessons were learned from the experience and several adaptations have been implemented in order to ensure that health professionals in the Halifax region are better prepared for future emergency situations. There is now greater recognition that the management of relocated patients, staff and medical equipment presents many unanticipated challenges, and that specific personnel need to be allocated to these tasks. This would help to ensure the communication of direct and accurate information about the needs of patients and staff. For example, it has been recommended that a familiar charge nurse or manager be appointed to staff at all times when they are relocated to an unfamiliar work environment. After Hurricane Juan, a toll-free phone number was established to provide hospital staff with up-to-date information during emergency situations. Adaptations to improve communication are being considered, including access to alternate satellite feed for TV coverage and digital access via the Internet that would allow for communication to the public about scheduling changes at hospitals during an emergency (such as cancelled surgeries and closed emergency rooms). A program is also being developed to train duty officers and administrators to respond to emergency situations. Finally, the District Emergency Response Centre has been moved to a new location equipped with improved systems for emergency power” Taken directly from: Health Canada (April, 2009). Emergency Management, Taking a Health Perspective. Issue 18 pages 18-19. This reference is accessible at: http://www.hc-sc.gc.ca/sr-sr/pubs/hpr-rpms/bull/2009-emergency-urgence/index-eng.php Adapted from Health Canada, 2009

Climate change sensitive health programs 14 Climate change sensitive health programs Infectious Disease Management Health of Northern Populations Air and Water Quality Emergency Preparedness Travel Medicine Mental Health Occupational Food Safety Adaptation Impacts Mitigation Seniors’ Health Health care system capacity Children’s Environmental Sustainable Development This figure presents examples of health programs that have and will continue to be sensitive to climate change impacts. Many of these programs are relevant to health care facilities directly in terms of patient care and through partnerships in the broader community (e.g. public health, emergency management). It will be important to consider how climate will impact health programs when considering mitigation and adaptation options.

Climate change risks to health care facilities COMMUNITY IMPACTS HEALTH CARE FACILITY VULNERABILITY Climate Change Impacts on Health Extreme weather events Food-and water-borne diseases Air quality Vector-borne diseases Health Care Facility Impacts Physical structures Patient services Health, safety and security of patients, staff and visitors This figure illustrates how climate change can impact health care facilities and provides examples of the areas where adaptation can be targeted to increase resiliency to climate change. Resiliency initiatives are needed to reduce impacts to physical structures of health care facility buildings, patient services and risks to health safety and security of patients, staff and visitors. Health Care Facility Adaptation Options Emergency management Facilities management Health services management

Background for the Resiliency Checklist Resiliency - Definition The ability of a community to withstand a disaster and its consequences (resistance) The ability of a community to “bounce back” to its pre-disaster level of functioning (recovery) The extent to which a community learns from the disaster experience and transforms this knowledge into more advanced emergency management functioning (creativity) The following three slides provides informaiton about how the resiliency checklist was developed. A resiliency definition was selected to inform a literature search. The literature search was done to identify resiliency indicators for health care facilities which were used to inform questions in the checklist. The resiliency definition presented in this slide is adapted from: Health Canada (2009). Emergency Management, Taking a Health Perspective. Issue 18 . This reference is accessible at: http://www.hc-sc.gc.ca/sr-sr/pubs/hpr-rpms/bull/2009-emergency-urgence/index-eng.php

Background for the Resiliency Checklist Resiliency - Indicators The tables in this slide and the subsequent slide present a matrix of indicators for each climate risk and each resiliency “pillar” (i.e. creativity, resistance and recovery). The list below is a legend for the acronyms used in this table. Legend of Acronyms: EW: extreme weather FBC: food-borne contamination HVAC: heating, ventilation, air conditioning ICS: incident command system FBI: food-borne illness

Background for the Resiliency Checklist Resiliency - Indicators This table in this slide and the subsequent slide present a matrix of indicators for each climate risk and each resiliency “pillar” (i.e. creativity, resistance and recovery). Legend of Acronyms: WBC: water-borne contamination WBI: water-borne incidence ID: infectious disease AQ: air quality HVAC: heating, ventilation, air conditioning PPE: personal protective equipment

Completing the Resiliency Checklist Checklist Sections General (4 questions) Assessing Climate Related Risks (19 questions) Risk Management to Reduce Climate Related Risks (45 questions) Building Capacity to Adapt to Climate Change (14 questions) This slide and the subsequent two slides provide suggestions on how to complete the resiliency checklist and how best to use results. This slide presents information about the types and numbers of questions found in the checklist.

Completing the Resiliency Checklist Responding to Questions Refer to tool kit questions presentation and respond as a group Respond using the following legend: Yes Somewhat / Sometimes No I don’t know Use the comments fields to provide information on: Information gaps Status of activities Other key stakeholders that may have primary responsibility Other pertinent information you wish to record This slide provides suggestions on how to respond to checklist questions.

Completing the Resiliency Checklist Best Use of Results Use your resiliency score to inform gaps and needs For resiliency areas where you need more information: Exchange information with other facilities Seek information from experts Refer to the Canadian Coalition for Green Health Care Best Practices Resource Guide Suggestions for how to use the results of the checklist for your health care facility are included in this slide.

Useful Resources Hospital Safety Index (WHO, 2009) http://new.paho.org/disasters/index.php?option=com_content&task=blo category&id=907&Itemid=884 Make Hospitals Safe in Emergencies (WHO, 2009) Disaster Risk Management for Health – Safe Hospitals: Prepared for Emergencies and Disasters (WHO, 2011) http://www.who.int/hac/events/drm_fact_sheet_safe_hospitals.pdf Addressing climate change in healthcare settings (WHO, 2009) Safe Hospitals in Emergencies (ISDR, 2010) http://www.wpro.who.int/emergencies_disasters/documents/SafeHospit lsinEmergenciesandDisastersweboptimized.pdf This slide presents resources that might be useful in informing how to make your health care facility more resilient to climate change.

Notes Page Use this space to document any discussion points, ideas, gaps and needs.