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

Abstract

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.

INTRODUCTION

When a disaster occurs, it may be necessary to evacuate the facility itself, including hospitals and nursing homes containing vulnerable people [1, 2]. Institutionalized people are vulnerable to evacuation and may suffer additional adverse health effects during an evacuation [3–7]. Hospitals and nursing homes have not developed guidelines for disaster evacuation and are found to be inadequately prepared for evacuation [8, 9]. In the event of a nuclear power plant accident, evacuation occurs over a wide area, and its impact on vulnerable populations, such as hospitalized patients [7, 10] and residents of nursing homes, is particularly devastating. For example, the risk of death due to evacuation was 1.82 times higher among residents of elderly care facilities than that of non-evacuees in Minamisoma, where evacuation advisories were issued to ~20% of citizens following the accident at the Fukushima Daiichi Nuclear power plant (FDNPP) after the Great East Japan Earthquake (GEJE) [11]. Moreover, it was reported that the relative risk of death was 2.68 among nursing home residents within 90 days of the GEJE [12]. Pneumonia was the most common cause of death 1 month after the disaster, and institutionalized people accounted for half of them [13]. Conversely, after the GEJE, 48% of patients evacuated from hospitals within a 20 km radius of the FDNPP died within 9 months, a significantly higher mortality rate than that of nursing home residents [14]. The failure to safeguard vulnerable populations during disasters correlates with increased disaster-related deaths [15], underscoring the imperative to address the unique needs of these individuals. Consequently, hospitalized patients emerge as a particularly susceptible group in the context of evacuation. The evacuation of vulnerable people from hospitals and facilities is a vital issue when considering the response to a nuclear accident [7].

In this study, we describe the history of evacuation during a nuclear emergency in Japan. Before the FDNPP accident, an area within 10 km of a nuclear power plant was designated as an Emergency Planning Zone (EPZ), where disaster prevention measures should be focused and enhanced [16]. In 2012, after the accident, the Japanese Nuclear Regulation Authority designated the areas within 5 km and 5 to 30 km from a nuclear power plant as the Precautionary Action Zone (PAZ) and Urgent Protective Action Planning Zone (UPZ), respectively, following International Atomic Energy Agency standards [17, 18]. In the PAZ, preparatory evacuation begins before the release of radioactive materials. In the UPZ, preparations are made to promptly shelter indoors, perform environmental monitoring, and implement urgent protective actions based on monitoring results before radioactive material release. Particularly, the evacuation of persons requiring special consideration in the PAZ begins early when an accident occurs at a nuclear power plant and a facility site emergency is declared. However, it was decided that persons requiring special consideration and care for increased health risks should not be forcibly evacuated. This population should be moved indoors to facilities with radiation-protection measures and evacuated when ready [18]. However, this was not decided for individuals requiring consideration in the UPZ. The difficulty of evacuation in the PAZ has been well-documented in past nuclear accidents [19–23]. In previous studies, several reports have documented the details of hospital evacuations in the areas corresponding to UPZ during nuclear disasters. For example, during the Three Mile Island incident in 1979, the Dauphin County Office of Emergency Preparedness prioritized the evacuation of patients in relatively stable conditions, while bedridden patients remained under care within the area. [24, 25]. Additionally, various reports regarding the FDNPP disaster have provided insights into the evacuation protocols and operational strategies conducted in psychiatric and internal medicine hospitals [26, 27] Moreover, a report has outlined the pivotal role of pharmacists in crisis management within hospitals during the acute phase of nuclear disasters [28]. However, limited information specifically addressing the complexities of making evacuation decisions within UPZs is available.

The GEJE occurred on 11 March 2011. On the same day, evacuation instructions were issued to residents within a 3 km radius of the FDNPP. The next day, these instructions were extended to people within a 20 km radius of the plant. The indoor evacuation instructions for the 20 to 30 km zone were issued on 15 March, and the resources in this area were depleted [29]. Hospitals in the area were not directly ordered to evacuate by the government from 11 to 18 March; hence, they had to make difficult decisions regarding their course of action. The political decision to evacuate hospitals was made on the afternoon of 18 March because of the decrease in human and material resources. Prior to this, hospitals in the area had to move back and forth between the decision to evacuate and not evacuate of their own volition. Although the concept of a UPZ did not exist at the time of the disaster, this summary of the situation of hospitals in this area provides essential insights into the problems that arise when making evacuation decisions while monitoring the current UPZ.

This study reports on three hospitals in the current UPZ of the FDNPP to clarify the problems and difficulties they faced regarding the evacuation of hospitalized patients in this area by summarizing records and interviews with hospital staff that evacuated inpatients after the GEJE and FDNPP accidents to learn lessons from the incident.

Case Presentation

Overview of the accident and the environment surrounding the three hospitals

At 2:46 p.m. on 11 March 2011, an earthquake, called ‘the 2011 off the Pacific coast of Tohoku Earthquake’, of magnitude 9.0 occurred. The subsequent tsunami caused an accident at the FDNPP. This series of disasters is collectively known as the GEJE. The city of Minamisoma, which hosts the three hospitals, is located in the Hamadori district of the coastal area of Fukushima Prefecture. The distance from the FDNPP was approximately between 8 and 40 km. During the earthquake, the population of the city was 71 494, and the population density was 179.4 people/km². After the earthquake, the area was divided into three regions based on radioactive contamination, and each part evacuated its residents [30]. In Haramachi Ward, Minamisoma, the intensity of the earthquake was six times lower than the Japanese seismic scale, and the tsunami reached the coastal area at 3:35 p.m. Six hundred and thirty-six people (0.89% of the population) were killed or went missing due to the GEJE. After declaring a state of emergency (Article 10 notification) following the station blackout, the government decided to evacuate the 3 km zone and EPZ indoors that day. On 12 March, instructions for the evacuation of the 20 km zone were issued. On 14 March, a meeting of the directors of hospitals in Minamisoma was held to share information on each hospital. On 15 March, instructions were given for the indoor evacuation of the area within 20 to 30 km of the FDNPP. Consequently, the supply of resources to the area almost completely ceased, and citizens’ lives became unbearable. From 18 March, mass evacuation of citizens took place.

Overview of the setting of the three hospitals

This study collected and analyzed publicly available resources related to Minamisoma Municipal General Hospital (MMGH), Watanabe Hospital and Omachi Hospital located in Haramachi Ward, Minamisoma. Five hospitals were located within 20 to 30 km of the city; however, only three allowed us to interview and collect information for this study. The location and basic information of each hospital are presented in Table 1 and Fig. 1.

We conducted interviews with 22 stakeholders (doctors, nurses, rehabilitation staff, pharmacists, administrative, and Disaster Medical Assistance Team (DMAT) staff). Seven doctors and administrative staff were interviewed about the hospital evacuation procedures and the difficulties that arose during the process. The interviews were conducted between 01 October 2020 and 16 March 2021. The duration of each interview was ~1 h. Each interview was transcribed, anonymized and shared with the research group. They ensure consistency with previously published information and other discussions.

MMGH is a public, disaster-based hospital and medical institution for the initial exposure to radiation in a nuclear disaster, located 23 km north of the FDNPP. At that time, the medical institutions for initial exposure to radiation in a nuclear disaster, including MMGH, were trained based on the guideline ‘On the state of emergency exposure medical care [16]’. However, the mock routine training content with the Tokyo Electric Power Company (TEPCO) did not assume a large-scale nuclear accident, and most staff members had little knowledge of radiation. MMGH has 17 departments and 230 beds and actively accepts ambulances, especially for neurosurgery, treating ~340 outpatients daily. In contrast, the other two hospitals are private. Watanabe Hospital is located 25 km from the FDNPP and specializes in acute care, with 175 inpatient beds and 300 outpatients per day. Moreover, it also received a large number of ambulances. Omachi Hospital is located 25 km from the FDNPP. It provides hemodialysis services and has 13 departments and 188 beds, 84 of which are convalescent.

Two private hospitals in this area excluded in the study were smaller than these three hospitals. One cared for 89 inpatients and 30 dialysis outpatients, and the other was an OB/GYN hospital with 19 beds.

The difficulties experienced by the three hospitals are presented in chronological order. Table 2 presents the time course of accidents and their occurrence in the three hospitals.

Difficulty 1: Acute phase of earthquake: acceptance of patients

The three hospitals received a large number of patients during the first 3 days.

Immediately after the earthquake, telephone services were unavailable, and many patients were brought to hospitals without prior notice. There were many cases of drowning and trauma due to tsunamis. Since 12 March, many hypothermic patients who could not be identified were brought in. At MMGH, three DMATs came and transported critically ill patients. They trained medical teams operating in the acute phase of a disaster to help victims or hospitals; however, the two private hospitals did not receive any external support.

Apart from patients who were injured or sick due to the GEJE, other individuals with vulnerable health were accepted. MMGH and Watanabe Hospital accepted patients and staff from nursing homes and hospitals within a 20 km radius. The nursing homes and hospitals were forced to evacuate, so MMGH and Watanabe Hospital provided them with space in the hospital. This situation was unexpected and caused friction among the people involved. Odaka Municipal Hospital, located within 20 km of the FDNPP, was evacuated to the MMGH. It was completely separated from the hospital and had little interaction with staff and patient care. The only factor that contributed to the maintenance of the hospital’s function was that a dietician from Odaka Municipal Hospital filled the position of the MMGH’s dietician who had been evacuated.

Difficulty 2: Acute phase of the disaster to the confusion phase: initial discharge and transfer coordination

Each hospital discharged patients who could walk independently or whose families could be contacted by landline phone on the day after the earthquake. In some cases, family members picked up the patients themselves. This reduced the number of patients and was a good experiment in reducing staff workload.

Transfer hospitals for patients who could not be discharged were coordinated using the physicians’ connections. Most hospitals accepted only a few patients, except for one hospital, which received 20. Until the government’s final decision to evacuate all three hospitals was made, the hospitals had to make transportation arrangements by themselves. This involved going to the fire station, whose premises were adjacent to the MMGH, to coordinate transportation until the telephone lines became operational. In some cases, they had to give up on transferring patients because of the complexity of coordinating transportation. After transfer arrangements, the patients left in each hospital were in poor condition, and most were bedridden.

Outpatient hemodialysis was continued at the Omachi Hospital until 15 March 15. Subsequently, some patients looked for a place to transfer independently; however, most were referred by the Omachi Hospital to other dialysis hospitals.

Difficulty 3: Disruption period: staff reduction and confusion

As Table 3 shows, the decrease in staff plagued each hospital. The staff and their families were also victims of the disaster; hence, in several cases, they evacuated with their families.

On 14 March, 11:01 a.m., the Unit 3 hydrogen reactor exploded, drastically changing the hospital director’s policy on hospital administration. At 11:15 a.m., a staff meeting was held at MMGH, and it was announced that the staff would work voluntarily thereafter. As a result, the number of staff members at the MMGH decreased from 296 (before the disaster) to 84 (~30%) as of 15 March.

The policy change in the MMGH affected Watanabe Hospital’s staff, and the number of staff members gradually decreased by the evening of 14 March. The following day, talk about dissolving the hospital was brought up, and the number of nurses decreased further. With many patients bedridden, the hospitals could no longer provide adequate care, including diaper changes and meal assistance. Before the earthquake, 167 staff members worked at Watanabe Hospital; however, as of 15 March, the number dropped to 33 (about 19%).

At Omachi Hospital, the situation was the same: 200 staff members had been reduced to ~42 (20%) as of 16 March. It took a long time before the decision to evacuate Omachi Hospital was made, and only 17 nurses remained on 19th March.

After 15 March, the external contractors at each hospital stopped working. The only exception was the food service company at Omachi Hospital. Consequently, qualified personnel at each hospital actively assume the roles needed in the hospital, regardless of their expertise. For example, male staff at MMGH provided radiation measurement and security services, while female staff at MMGH and Watanabe Hospital provided food services.

After 17 March, the evacuation of all citizens began, and the staff became anxious and impatient and wondered how long the situation would continue. Around this time, Omachi Hospital complained to the media about the depletion of supplies and personnel resources, leading to the arrival of several volunteers, the return of two nurses and the delivery of relief supplies.

Difficulty 4: Acute phase of the earthquake to the disruption phase: infrastructure status and suspension of logistics

At the beginning of the disaster, the MMGH had its own emergency power source; however, a water pipe burst (repaired and restored on the same day) and gas was stopped. Omachi Hospital initially stopped its water and gas use but could use them around 13 March. Watanabe Hospital experienced no infrastructure damage. At all three hospitals, the infrastructure was restored by 14 March, and two-way communication systems, such as mobile phones and the Internet, were available to some extent.

However, logistics halted on 15 March when indoor evacuation instructions were issued for the 20 to 30 km zone. Due to voluntary restrictions by vendors, many refrained from entering the 50 km zone, which was broader than the evacuation instructions; hence, food, medicine, oxygen, fuel oil, etc. were depleted. Although the Japan Self-Defense Force (JSDF) began supplying food to the MMGH on 15 March, it was primarily carbohydrates with no fresh food. The impact on private hospitals was even more significant, with Omachi Hospital reducing its meal services from three to two times a day on 17 March. Furthermore, the media did not come in, and the situation in Minamisoma was no longer reported. On 17 March, the Minamisoma governing body was worried about the situation and called for an evacuation outside the city. They prepared an evacuation bus for their citizens. On 18 March, the director of the Omachi Hospital appeared on TV and complained about the situation.

Difficulty 5: Evacuation decisions: absence of decision criteria

The circumstances leading up to the decision to evacuate differed among the hospitals.

Watanabe Hospital could not make a decision to evacuate or shelter in place because of disagreements among the upper management. Initially, the director judged that the effects of radiation would be minor and decided to provide shelter. However, early on the morning of 15 March, the information that the hospital was to be dissolved came from other managers, and the staff decreased. Hence, it has become difficult to maintain hospital functionality. On the night of 15 March, the hospital director was able to find hospitals to transport patients to, and Watanabe Hospital decided to evacuate all patients and close the hospital.

In contrast, Omachi Hospital and MMGH were very different. On 17 March, the MMGH consulted the mayor of Minamisoma, Mr Sakurai, and decided to evacuate the hospital because of the difficulty in maintaining it. On 18 March, the Minister of State for Disaster Management, Ryu Matsumoto, visited Minamisoma and spoke with hospital officials, including those from the MMGH. In the evening, the central government made a formal political decision to evacuate hospitals within a 30 km radius of the FDNPP. This notice was also given to Omachi Hospital in the evening, and preparations began to evacuate all inpatients. Hence, the decision to evacuate hospitals was made on an ad hoc basis. The decision to conduct a hospital evacuation and its criteria were not discussed in advance at any hospital. Therefore, there is no process for comparing the risks and benefits of evacuation. However, the fact that the government’s intervention allowed the evacuation to proceed in a concrete manner was a good thing in the midst of this chaos.

Difficulty 6: Evacuation preparation period: lack of preparation time

Only the JSDF and police vehicles were allowed to enter the 30 km zone by the time the evacuation began on 15 March. Therefore, it was necessary to conduct screening and vehicle transfers outside the 30 km area and, in some cases, to create a list of names and transport them to their destinations. In addition, the time between the decision to evacuate and the start of the evacuation was minimal (less than half a day in each case), making it difficult to adequately prepare. Consequently, it was impossible to accurately communicate the number of individuals, their medical conditions and their histories. Table 4 summarizes the evacuation procedures at each hospital.

The evacuation of Watanabe Hospital, the first hospital to be evacuated, proceeded the most smoothly. From the morning of the 16th, the triage of patients and the arrangement and transportation of means of transferring them to the hospitals began. Negotiations for patient transfer were divided into patients who were the most critical, orthopedic and other categories. Watanabe Hospital did not make patient referral documents and used paper medical records as a substitute for the patient to carry; this was a good way to reduce preparation time. One nurse accompanied each vehicle, and if a staff member wished to return to Minamisoma, the hospital vehicle followed because the transport vehicle could not re-enter Minamisoma. These transfers took place from 16 to 17 March, and it was not until the early morning of the 18th that the staff returned from the last transfer transport. The hospital was cleaned on the 18th, and the two most critically ill patients (with a ruptured esophageal varix and terminal cancer) who could not be transferred died on that day. None of the critically ill patients died during transport; however, one died after transfer due to insufficient sputum sucking. It was impossible to contact the families regarding the transfer of patients to the new hospital; hence, they were mainly approached by the hospitals to which the patients were transferred. Until around 20 March, Watanabe Hospital accepted inquiries from families. However, since then, Watanabe Hospital has closed completely.

The MMGH began a wide-area transport to Niigata Prefecture when the decision to evacuate was made. The MMGH worked throughout the night to triage 107 patients, formulate a transport plan, prepare patient referral documents and sew nametags. When the attending physician was absent, another physician took over writing the medical information forms. Patients from the MMGH and Omachi Hospital were transported from their respective hospitals to the primary triage points in Kawauchi Town and Fukushima Medical University Hospital, depending on the day, and then to the secondary triage points in Niigata or Gunma Prefecture, depending on the hospital. The final decision was made at the hospital where the patient was transferred and transported. At the MMGH, besides the patients transported to Niigata, four patients who were judged to be unable to withstand transport were transported to Fukushima Medical University Hospital. Twelve patients were transported to hospitals in Fukushima City through their physicians’ connections. After patient transfers on the 20th, MMGH closed its inpatient function and shifted its focus to emergency care and drug prescriptions for those who had lost their daily prescription drugs and could not visit their primary care doctors or evacuation center support activities. On 4 April, outpatient treatment with internal medicine and surgery was resumed.

Omachi Hospital was the last hospital to be evacuated. The local government did not provide transportation to the docking sites; hence, the director asked the university where he graduated, located in Tokyo, to arrange for a Metropolitan Police Department vehicle. On 20 March, 13 patients were transported to the Fukushima Medical University. In addition, several transfers were not officially recorded. Five patients died within 2 weeks and 15 within 2 months of being transported to Gunma Prefecture and Fukushima Medical University. In addition to the harsh transport environment, the cause of death was a lack of medical history sharing after transport.

DISCUSSION

This study discovered that the uncertain timing of evacuation decisions in the UPZ significantly affected a hospital’s ability to function well. This uncertainty caused low morale among hospital staff and shortages in fuel and supply. The UPZ has a system for assessing radiation doses and making evacuation decisions. In the immediate aftermath of the accident, there were times when the hospital staff did not know the scale of the accident and were uncertain whether their locations would be ordered to evacuate or instructed to stay indoors. As a result of being forced to make efforts with no visibility or foresight, hospital staff became exhausted, and their morale declined. The number of staff members decreased sharply in all the hospitals reported in this paper. In previous studies dealing with PAZs, staff morale was maintained [19, 20], which may depend on the characteristics of the UPZ.

The interruption of logistics was also a significant problem for maintaining functionality. As there is a waiting period for evaluation in the UPZ, during this time, even after the evacuation is completed or shelter is in place, it is essential to secure logistics, including oxygen and fuel oil, which are necessary for life support, as has been pointed out in earthquakes or other disasters [31, 32]. One of the reasons Watanabe Hospital decided to evacuate was the heavy oil shortage. The evacuation standard (50 km) set by the logistics provider, separate from the Japanese government’s evacuation order (30 km), had a strong influence on this situation. In the UPZ, it is essential to secure a supply of materials when shelters are in place.

Another problem was that the evacuation criteria were inadequate. In this case, the decision to evacuate was haphazardly made. Several studies have been conducted on decision-making when evacuating hospitalized patients [33–36]. However, to the best of our knowledge, although the concept up to decision-making has been developed [8], the specific factors to be considered in this process have not been systematized [37]. Furthermore, in UPZ, besides the factors to be considered in general disasters, radiation protection must also be considered. It is necessary to consider the evacuation criteria in the UPZ. It is also necessary to share information with each hospital and stakeholder when conducting dose assessments and determining the subsequent response. In times of disaster, the decision to evacuate should be made after weighing its advantages and disadvantages.

In this area, exposure was relatively limited: outdoor radioactivity levels in MMGH on the day after the GEJE were 20 μSv/h at 1900 and 12 μSv/h at 2000; after 13 March, they were generally kept below 10 μSv/h and indoors were 2.3 μ Sv/h or less indoors [27]. The average external exposure dose for residents of Minamisoma during the first 4 months (11 March 2011–11 July 2011) was estimated to have been 0.7 mSv [38], which was relatively limited. Even in such an area where exposure doses are expected to be limited, it is important to consider evacuation plans from the perspective of radiation protection.

It was also found that the increased burden on medical staff due to accepting patients from surrounding areas and stopping vendors outside were significant problems in maintaining hospital functions. Due to the mandatory evacuation from a 20 km radius, there was a temporary evacuation from a geriatric healthcare facility to Watanabe Hospital and from Odaka Hospital to MMGH. At the time, there was a shortage of fuel and friction between the staff because of original disagreements in some facilities. Modern hospitals often outsource some of their operations to external contractors to improve management efficiency. However, because the decision-makers of external contractors are the contractors themselves, it is not certain whether they will remain in the event of an emergency. At this time, almost all vendors withdrew except for the food service at Omachi Hospital. This created a situation in which the remaining professionals at each hospital had to undertake the work of these businesses, which placed a heavy burden on them. This leads to a direct decline in the quality of patient care. Therefore, in the future, hospitals and administrative districts in such areas should plan to maintain hospital functions in the event of a disaster and build a disaster prevention system for the entire region.

In the UPZ, it is challenging to continue medical care even when people remain indoors. Immediately after the earthquake, each hospital accepted many people directly affected by the disaster, including those with drowning and trauma. Moreover, they received patients and staff from nursing homes and hospitals forced to evacuate within a 20 km radius. Except for MMGH, the two hospitals did not receive external support. Moreover, the number of staff gradually decreased immediately after the earthquake because of accompanying family members evacuating, evacuating together to remote areas due to concerns about children’s exposure to radiation and being instructed to evacuate from homes within a 20 km radius. Furthermore, after the hydrogen explosion at the Unit 3 reactor on 14 March, the medical staff at MMGH decreased drastically because working at the hospital became voluntary rather than compulsory, and the indoor evacuation instructions became a stigma as the area where the hospital was located was dangerous. Outside contractors were pulled out as early as 15 March, and no hospital could rely on them. Consequently, the number of hospital staff members decreased to ~30% at MMGH, 19% at Watanabe Hospital and 20% at Omachi Hospital. Furthermore, the hospitals were unable to provide adequate care, including diaper changes and meals, for many bedridden patients. This is consistent with previous studies [32, 39–41] in which medical staff and logistics were reduced during a disaster. When choosing to stay in a place, it is essential to ensure the safety and mental follow-up of medical staff [42–47], as well as maintain the logistics of their families [48]. To preserve hospital functions during disasters, it is necessary to consider the maintenance of these points.

The responsibility for the excess deaths and other health problems caused by evacuations is unclear. In Japan, the concept of ‘disaster-related deaths’ has since been used to hold the national and local governments [49], and in some cases TEPCO, accountable in the form of condolence payments and Alternative Dispute Resolution (ADR). However, hospitals are at risk of litigation and may not make appropriate decisions [37]. Therefore, in times of disaster, it is necessary to support exemption from liability for decisions based on conscience and circumstance.

One of the major problems was that public and private hospitals had very different responses to the evacuation, and MMGH, a public hospital, was given preferential treatment in terms of ambulance arrangements and schedules. In contrast, Watanabe Hospital completed its evacuation through personal connections with its administrators. However, Omachi Hospital’s organization collapsed as it could not decide on a way forward. There was no communication between the hospitals, and the organizational breakdown of Omachi Hospital accelerated because they did not know what other hospitals were thinking about and working on. Differences between public and private hospitals have been documented in previous studies [29]. When building a community disaster prevention plan, the focus is often on the primary hospital, which is typically a public hospital. However, it is necessary to include private, small- and medium-sized hospitals in the plan.

With limited medical resources, these three cases reduced the burden of evacuation, leading to rapid hospital evacuation. The first is the communication of medical history using medical records. In the case of hospital evacuations in the UPZ, the staff and material resources were reduced before the decision to evacuate was made. Once the decision was made, the preparation time was minimal (less than half a day). In some cases, essential staff members were absent, making it challenging to prepare referral letters to other hospitals and sufficiently communicate the exact number of people, symptoms and medical histories, which resulted in death and a decline in activities of daily living immediately after transport. In contrast, Watanabe Hospital did not prepare a referral letter and kept paper medical records. This shortened the preparation period for evacuation and made their evacuation the smoothest. Periodic inpatient summaries can be prepared in hospitals with electronic medical records, which can be printed or sent electronically in case of a disaster.

The second issue concerns the government intervention. The staff of each hospital regularly coordinate the transfer of patients using connections around the prefecture. However, when a large-scale disaster occurs, regional hospitals, which are the recipients of transfers during normal times, are also in turmoil and, in many cases, cannot undertake a large-scale evacuation. Under such circumstances, the MMGH and Omachi Hospital could accept evacuees on a prefectural basis through government intervention. This could outsource the coordination of hospital transfers to the hospitals in charge of each prefecture.

Third, each hospital discharged patients in stable conditions as early as possible. From the day after the earthquake, hospitals discharged patients who could walk unaided or whose families could be contacted using landline phones. In some cases, families picked up their patients themselves. Patients who could not be discharged were coordinated through personal connections with doctors, and in many cases, only one or two patients were accepted. In other instances, 20 patients were received by a single hospital. In this way, they could focus their limited resources on patients who needed more care [50]. Given that previous studies have shown that Japanese hospitals are vulnerable to chronic care and stockpiling, it is important to discuss ways to reduce the burden of evacuation [51].

This study has several limitations. One is the recall bias of the interviewees. Second, it was impossible to interview all medical institutions within a 20 to 30 km radius of the FDNPP, and other hospitals may have had other problems. Moreover, the GEJE was a triple disaster consisting of earthquakes, tsunamis and radiation; hence, it requires more complicated operations than a single radiation disaster. Therefore, it may be difficult to generalize the lessons learned from this study to a single radiation disaster. Despite the existence of such limitations, this paper shows the difficulties that should be envisaged to protect hospitalized patients in the current UPZ and the innovations that can be used when evacuating patients.

In conclusion, we found from our interviews with officials who had evacuated patients from three hospitals within a 20 to 30 km radius from FDNPP that they had difficulty deciding whether to evacuate, and sometimes it caused hospital functions to fail in the GEJE. Therefore, disaster prevention plans for areas where power plants are located should include a perspective on maintaining community functions, including hospitals that serve vulnerable people.

ETHICAL CONSIDERATIONS

The study was approved by the ethics committees of MMGH (approval number: 2–19) and Fukushima Medical University (approval number: General 2019–269). Written consent for the study was obtained from all participants.

ACKNOWLEDGEMENTS

The description of this case is not intended to show the skillfulness of hospital management but to provide perspective and material for analysis and discussion. In the unprecedented event of the triple disaster, a variety of incidents occurred, some of which, in hindsight, 10 years later, may have included overreaching flaws. We do not intend to criticize them. Every event happened despite the best efforts of each medical professional, whom we sincerely respect.

We would like to thank all the people who participated in the interviews and those who arranged and transcribed the interviews, including Kyoko Harada, Yuka Harada and Zhu Xu Jin. The authors are also grateful to Mr Masatsugu Tanaki of MMGH for technical support. We would also like to thank Editage (www.editage.com) for their English language editing services. In the course of manuscript preparation, the authors used the DeepL tool exclusively for the purpose of enhancing English language expression. Subsequent to utilizing this tool, a comprehensive review and editing process was conducted by the authors to refine the content. Additionally, the manuscript underwent meticulous editing by proficient scientific editors with English as their first language. The authors hereby acknowledge full responsibility for the content presented in this publication

CONFLICT OF INTEREST

The authors declare the following financial interests/personal relationships, which may be considered as potential competing interests: O.A. received financial support from Medical Network Systems, Inc., Kyowa Kirin Inc. and Taiho Pharmaceutical Co., Ltd.

FUNDING

This work was supported by the Radiation Safety Research Promotion Fund (grant number: JPJ007057) organized by the Nuclear Regulation Authority, Japan and the Program of the Network-Type Joint Usage/Research Center for Radiation Disaster Medical Science.

PRESENTATION AT A CONFERENCE

Part of this article was presented at the 5th Workshop of Network-type Joint Usage/Research Center for Radiation Disaster Medical Science.

REFERENCES

Author notes