Fire prevention: improving staff readiness.

A fire protection consultant outlines the elements required

The evacuation of a nursing home during a fire is different from that of any other building. Residents have varying degrees of wellness and ambulation capabilities, as well as physical conditions that limit their ability to evacuate a facility quickly. Subacute patients are often medically fragile and may be dependent upon ventilators or IVs. In addition, the number of staff available to assist in evacuation varies according to the shift and time of day. All these factors must be considered in developing an effective fire response and evacuation program.

Such a program can exist only after the following three objectives are accomplished:

1. A fire protection survey of the building, as it relates to the evacuation system. From a liability standpoint, it is imperative that fire safety procedures are supported by the building's structure.

2. Modern, proven health care facility evacuation techniques. Standard procedures used for other occupancies, such as schools and hotels, are not effective for health care facilities.

3. Staff training under realistic fire conditions. In the beginning moments of a fire, the nursing home's staff are the only individuals available to rescue nonambulatory residents and move them to safety. It is unrealistic to expect them to react effectively in an actual fire situation without any prior experience. Fire drill systems must be in place to ensure that staff and their supervisors are prepared to react appropriately at all times.

The Fire Protection Survey

This survey examines the building from a fire evacuation standpoint. It may be conducted by the nursing home itself, using the procedures outlined here, or contracted to a fire prevention consultant for approximately $250 to $1,000, depending on the size of the facility.

The survey begins with an examination of the building structure itself. If the building is combustible but does not have a complete automatic sprinkler system, evacuation procedures must be designed so that everyone is eventually evacuated from the building, since no "safe areas" can be presumed available. If, on the other hand, the building is fully sprinklered and/or is a fire-resistive structure with fire/smoke walls, compartmentalized evacuation may be considered. Residents not in the fire area are protected "in place." This type of evacuation, supported by building codes and the National Fire Protection Life Safety Code, has become necessary in light of the physical condition of today's nursing home residents and the staffing complements typically found during the evening hours. Both of these factors make evacuating the entire nursing home population in an acceptable length of time extremely difficult.

Additional structural features must be evaluated to ensure the facility's ability to prevent the spread of fire and smoke while residents are being relocated to safe areas, i.e.:

* The heating, ventilation and air conditioning system (HVAC) should be inspected to ensure that the ventilation system will not spread smoke mechanically. Automatic shut-down of the air handlers upon activation of the alarm, and smoke-actuated dampers at ducts' penetration of fire/smoke barrier walls are important features. Code exceptions exist for engineered smoke-control systems and quick-response sprinkler systems.

* Vertical smoke spread via elevator and utility shafts is one of the most common ways that smoke reaches upper floors and forces a multistory evacuation. Fire-resistive gasketing of elevator shaft doors or shaft air pressurization have been used to retard smoke spread through the elevator shaft. Proper sealing, as well as fire dampering the penetrations into vertical utility shafts, are important preventive measures.

* Fire alarm and detection systems provide invaluable assistance. Smoke detectors in corridors or resident rooms provide early warning of an incipient fire and give staff more time to remove residents from immediate danger. Automatic fire department notification -- directly or through central monitoring stations -- helps ensure rapid response times. Delayed fire department notification often surfaces as a key problem in investigations of health care facility fires where life has been lost.

* Smoke barriers, corridor walls and room doors are important defensive tools. If the fire can be contained to the room of origin, these "tools" provide more time for evacuation and fire department travel to the site. Compartment isolation by smoke barrier doors and their walls allows residents to be protected in place immediately outside the fire zone. However, to be effective, these walls must have full fire protection integrity from floorslab to underside of floorslab or roofdeck above, and from outside wall to outside wall. There are some exceptions to these requirements for walls that separate resident treatment areas from hallways when the building is totally sprinklered.

* The resident room door is probably the single most important fire protection feature in the nursing home. Many investigators have demonstrated that a closed door provides residents with a much better chance of survival in a fire. When the door is opened, even firefighters are unable to arrive in time to save the residents in the fire area. The door must be of appropriate construction (i.e., one-and-three-quarter-inch, bonded-core giving 20 minutes of fire protection), and have latching mechanisms that enable the door to remain closed, even against the pressures of a fire.

Response and Evacuation Procedures

Written procedures should outline the actions required of staff upon discovery of a fire or activation of a fire alarm. Note: The emergency fire procedures are more easily read and remembered when written as a separate document rather than as a section in a training or policy manual.

The following three sections must be outlined in the general procedures:

1. Actions upon discovery of a fire:

a. remove the person in the immediate fire area;

b. close the door to contain the fire;

c. activate the fire alarm;

d. close all remaining doors in the fire area.

These procedures should include a clear statement of priority, i.e., the safety of the resident followed by isolation of the fire. The procedures are to be carried out regardless of the area in which the fire is located. Because anyone in the facility might discover a fire, all employees, including support staff, should be trained to carry out the above procedures.

2. Response to fire alarm activation:

In this section, employees are told where to respond when they hear an alarm. It is important that a sufficient number of staff members respond to the fire area to assist in evacuation. Most facilities that have experienced a fire report the need for automatic response to fire areas during evening hours by predesignated nursing personnel -- a more efficient arrangement than one in which the charge nurse must call other nursing stations for assistance. There is always a core response to any fire by specific personnel, including administration and maintenance staff.

One breakdown in fire procedures we have observed consistently is a lack of communication among staff and with firefighters. We have found that designating the nurses' station of the fire area as the inside "Control Center," with the DON or nursing supervisor present, is most effective for resident care areas. It is actually the charge nurse who directs the evacuation in the event of a fire in a resident care area. The administrator on the premises or on call should be stationed at the location designated as the "Incident Command Center" by the fire chief. In larger facilities, portable radios help to facilitate communication between the Command Center and the Control Center.

When they arrive, the fire department must be met by a staff member. It is imperative that they be taken to the fire by a route that does not penetrate the smoke barrier doors, beyond which the residents are being evacuated. This is especially important when hose lines are laid within the facility smoke compartment.

3. Evacuation Procedures

A four-stage evacuation set-up has been proven successful.

STAGE I: removal from the room of fire origin;

STAGE II: horizontal evacuation beyond the fire/smoke barrier doors;

STAGE III: vertical evacuation from the level of fire origin;

STAGE IV: evacuation from the building.

Each stage moves the occupants of the building farther from the fire and is increasingly more difficult for staff to accomplish. It is important that the fire protection features of the building be evaluated before this multi-stage evacuation plan is tailored to the$facility. These general procedures can then be shaped into unit-specific plans that include such steps as safely disconnecting medical equipment (feeding tubes, catheter drainage equipment, IVs, ventilators) to remove residents from the fire area. An area designated for resident relocation must be listed, keeping in mind the need to continue life support functions.

Staff Training

The staff must be oriented to these procedures when they are hired. However, for staff to be effective in the use of their fire response and evacuation procedures, they must experience the conditions that might exist in the event of a fire. Direct supervisors, such as charge nurses and department heads, must assume responsibility for the continuing education of the staff along these lines, since they are the people who will have to direct their staff members through the first crucial moments of a fire in their area. Therefore, fire drills should serve as a check of the state of readiness of a particular unit or department. During those drills, employees who are not carrying out procedures effectively on their own should be guided through them by their immediate supervisor. These supervisory personnel should also be reviewing the procedures with staff on a monthly basis.

In any event it is most important that staff have realistic training in the proper responses to situations they might encounter before the arrival of firefighters. This might include smoke awareness training or suppression of fire on a resident's clothing, under carefully controlled circumstances using expert instructors. Training in the use of portable fire extinguishers is an effective way to familiarize staff with the characteristics of a small fire, as well as the operation of the device. They might also learn effective techniques for removing nonambulatory residents from fire areas, such as techniques we have developed (used to move residents of varying weights while minimizing the risk of staff back injury).

Conclusion

The thought of being responsible, and ultimately accountable, for someone else's life in an emergency situation is daunting, to say the least. The more confident your staff becomes of their ability to carry out the facility's fire procedures effectively, the more likely they are to be able to rise to the occasion, should such an occasion occur. The key, as always, is prevention, education and re-education until fire procedures become instinctive. The nursing home that is prepared for the worst is the nursing home least likely to have to deal with a costly or even tragic outcome.

Resident Rescue

A resident rescue technique developed by Russell Phillips & Associates, Inc., along with a physical therapist and a group of nurses, enables two people to remove a resident from bed and into a safe area without any lifting or carrying:

* The top covers are pulled off the bed;

* The bottom sheet is pulled out and both sides of the sheet are rolled up against the resident;

* One person slides the resident to the edge of the bed by pulling on the sheet;

* The person at the foot of the bed lowers the resident's feet to the floor;

* With knees bent, the person near the head of the bed slides the resident down his/her knees onto the floor;

* Using the sheet like a sling with the resident in the center, each staff member picks up one side of the sheet and drags the resident along the floor to non-fire area.

Staff members trained in this procedure have been clocked at 20 seconds from arrival at the door to exit with the resident. In a true fire situation, staff members have carried out the rescue in only 6 seconds. While designed for two people, the procedure can be carried out by one, performing the tasks one at a time.

Russell Phillips is President/Owner of Russell Phillips & Associates, a Fire Protection Consulting Firm with offices in Rochester, NY and Elk Grove, CA.