BY BRENDA K. FARLOW
In July 2012, a large and prolonged heat wave that caused many severe storms struck Chicago, Illinois. One evening, these two weather factors collided in the Northlake area, causing a widespread and prolonged power outage, which affected the Concord Place Retirement and Assisted Living Community. Concord is a 16-story high-rise that houses approximately 325 residents, each of whom has a private apartment (although there are a few couples) and a different level of mobility. Concord offers services ranging from independent living to assisted living to home health care nursing. The night of the power outage, the overnight temperature was 84°F.
Fire Operations at Senior Living Facilities
Concord’s backup systems include a diesel generator that runs one elevator, the emergency lighting, the fire pump, and the air-conditioning system. That night, the radiator on the diesel generator blew out and could not be repaired after several hours of attempts. Losing the main power and the backup generator meant all elevators were out of service, the fire pump was not working, and the sewer pumps could not work so toilets could not be flushed; sewage began to back up. People began to experience heat-related and sanitary health issues. The Northlake (IL) Fire Protection District was dispatched to the building for a fire alarm activation and on arrival noticed a complete lack of power to the building. Because of the serious safety hazards, the owner was given one hour to repair the generator or begin an evacuation. Evacuation began at 2115 hours.
For fire departments, evacuations are difficult and labor intensive; difficulties arise because people are not always cooperative. What type of planning and logistics does it really take to evacuate a senior citizen living center? Foresight in contingency planning, along with calm, coordinated communication and action, is key to minimizing fatalities and to avoid aggravating injuries and illnesses during a disaster.1 Too often, adverse weather conditions or other unforeseen events can render a written plan ineffective. “Without a plan that can cope with two phenomena at once, the entire plan can be thrown into chaos.” (1) Inadequate preparation goes hand in hand with confusion and panic. (1) Seniors are especially at risk as they are considered one of the most vulnerable populations.
Disasters can be particularly serious for elderly victims with inadequate transportation and limited personal support.2 Frail elderly are defined as those with serious physical, cognitive, or psychosocial problems. The three most common medical issues of this group are hypertension, diabetes, and cardiac problems. Although preparation for a disaster is essential, it is often left to those affected to determine how they want to prepare. The elderly may not know how to prepare or where to find that information and thus may find themselves at increased risk. More information must be given than just, “Grab your medications and eyeglasses.” Maintaining a “special needs” registry may be a good idea for facilities and towns with elderly people living on their own. (2) This list may also include the residents’ ability to self-evacuate (e.g., ambulatory or bedbound).
Until Hurricane Katrina, hospitals were the main focus of evacuation planning. Now, however, skilled nursing and nursing homes’ needs and potential impacts have emerged.3 Sheltering in place and evacuation both carry risk. While preparing evacuation plans, transportation and decision making remain two issues requiring more work. Although United States nursing homes are required to maintain an evacuation plan, compliance is not always robust.4 Evacuation in assisted living (supportive living) also varies greatly. In an emergency, “implicit in the decision-making process is the ability for the facility to safely shelter residents for a prolonged period of time.” (3)
There are many costs associated with the complete evacuation of a supportive living or nursing facility. In some states, long-term care facilities are not recognized as health care facilities. Senior living centers that are not designated as skilled or assisted living are not regulated by the state. This important designation is imperative for federal reimbursement under the Stafford Act. (3) Another note, the Stafford Act specifically prohibits the reimbursement of for-profit facilities; thus, 70 percent are ineligible. (3) At the state and county levels, such nondesignation may affect the facility’s priority during planning at the emergency operations center. If a facility is not included in the planning, there may not be enough “special needs” facilities or supplies available at the evacuation point.
An emergency situation can exist with or without injuries and death. A good rule of thumb is as follows: Ten or more people facing a life-threatening emergency qualify as a mass casualty. (1) Evacuation can be associated with a twofold mortality risk. (4) Evacuation number and distance are factors in that mortality. It is not possible to know with certainty whether increases in mortality are the result of stress, the facility’s evacuation processes, or the quality of care at evacuation sites. (4) Further, the initial evacuation is the most dangerous event, not the return trip. (4) Evacuation has adverse effects not only on mortality but also on clinical status with relation to chronic illnesses.
There are many forms of evacuation including protective, preventive, and rescue.5 The form of the evacuation depends on its timing and the duration. A rescue evacuation takes place immediately following an adverse event to ensure safety. Individual behavior, planning, and the environment in which the evacuation occurs are three factors affecting the evacuation outcome. (5) The building’s physical characteristics may not support the preferred behavior of the individual. Where the severity of the infrastructure collapse and structural damage does not in itself warrant an evacuation, exercise careful judgment in deciding the acceptable level of risk to a resident’s health, life, and safety. Of course, some of these decisions must be made in conjunction with the building department and possibly structural engineers. It is possible that the evacuation process itself will yield a higher mortality. (4)
Fire departments all over the country prepare for evacuating buildings, especially nursing homes, schools, and hospitals. A general assumption is that an evacuation will only occur during a fire, a hurricane, or a building collapse. There is very little planning since it is assumed that citizens will cooperate, only one issue will occur at a time, and the appropriate resources will be available.
THE CONCORD EVACUATION
The number one issue the night of the Concord evacuation was how to address the evacuation priority of residents. The residents were categorized as sick or not sick. Responders then instituted further triage into those who were sick or experiencing heat-related issues requiring transport to the hospital and those who required medical surveillance after removal from upper floors.
The Concord facility manager provided the fire department with a list of medically dependent residents, including those on oxygen and other machines such as continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) machines for sleeping. This was the first group evacuated. By the time the evacuation started, the power in the building had been out for several hours. Residents with oxygen concentrators had begun to run out of stored and available oxygen tanks. However, this did not mean these residents were in distress. Following the primary evacuees, the resident removal priority was as follows: sick (i.e., heat-related or chronic illnesses), the nonambulatory, and finally hospice patients.
A top-down evacuation was instituted following the first wave of evacuees. Firefighters and paramedics ascended the stairs with stair chairs and medical bags to begin removing residents. Those who were ambulatory had self-evacuated aided by the Concord staff. The removal of ambulatory residents was still ongoing when crews began the top-down evacuation. This was not helpful since it made accountability of residents and staff members difficult for the incident commander. Also, as residents saw they were being bypassed for evacuation because of the priority system, they began calling 911 on cell phones and were also waving down firefighters, begging to be evacuated. Thus, the evacuation prioritization system did not work.
There were many obstacles to physically evacuating the residents including lighting, equipment needs, high heat for responders, communications, and the stairwell traffic flow. Since the power had been out for several hours by the time of the evacuation, the battery-powered emergency lighting in the stairwells had failed, and the three stairwells were pitch black.
It was necessary to bring stair rescue chairs to remove patients. Although each crew ascended with a stair rescue chair, the device was sometimes not of the design with which they were familiar. Newer style stair rescue chairs have a tread system that allows the chairs to glide over the stair tread and reduces the amount of effort and personnel it takes to remove a victim. Older models, however, do not have this feature and require lifting the patient and hand-carrying him down the stairs. This is fine if you have one patient, as is most common. However, it becomes very labor intensive with multiple patients and multiple floors.
It was extremely warm for responders in the building; the heat was increased by the amount of physical labor they were doing. Fire departments responded to the evacuation wearing turnout gear and had not brought shoes to change into. The firefighters proceeded to wear the turnout pants during the entire evacuation.
Communication was also an issue. The medical unit leader had fire departments, Concord employees, and private ambulance service providers helping in the evacuation. There was no interoperability among systems. Concord employees used handheld radios, fire departments used VHF 800 MhZ radio systems, and private ambulance providers used cell phones.
The largest hurdle was the control of the building’s three stairwells. At one point, people were going up and down in the same stairwell, requiring personnel and residents to step out of the stairway into the hallway outside the stairwell for others to pass by. This added time and aggravation to the evacuation until it was resolved. This problem was addressed by a neighboring town’s emergency services disaster assistance group stringing lights in the stairwells.
LESSONS LEARNED
Evacuation. Prehospital triage systems focus on injury, not illnesses. EMS providers must adapt these systems to include medical issues, whether for evacuation or for medical mass casualty incidents. Evacuation was handled in different areas. Sick people or nonambulatory people requiring transport by stretcher exited by the east side of the building. Private ambulances transported nonambulatory patients with no complaints. Fire department ambulances transported the sick people to hospitals in the area.
For the stairwell evacuation, one of the three stairwells should have been designated as an ascending staircase and the other two as descending staircases, which would have prevented the bottleneck in all three stairwells (photo 1). Although this was a labor-intensive operation, evacuation equipment was needed. Consider purchasing and storing hospital-type evacuation sleds or other devices at the facility.
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| Photos by Eric Swanson. |
Ambulatory and nonambulatory residents who did not require ambulance transport were evacuated from upper floors into the lobby area, which was quite warm, reaching 87°F by 9 p.m. (photo 2). Some residents were moved outside along the sidewalk while transportation arrangements were made.
Several problems resulted. First, the exhaust of the initial buses was directed on the waiting residents who were wheelchair bound and at the level of the exhaust pipe. Second, the first group of buses ordered was tour buses, the stairs of which were too steep for residents to climb, and the aisles were not wide enough to accommodate walkers. After several hours, those buses were released from the scene. The next set of buses ordered was mass transit buses, which had wide aisles and low stairs and the bus’s front end would lower when the door opened to make it easier for residents to board. Although a much better option, the buses arrived with very little fuel since they had been returning to the depot at the end of their shift, when requested. Just as a fully loaded bus began to leave, it ran out of fuel, requiring the residents to be moved again.
A second bus arrived to take those residents. As the second bus was being loaded, it was struck by a fire truck as it turned the corner. Although the damage was minor, residents had to be moved yet again into a third bus. The bus company’s accident investigation protocol required that the bus be inspected before it could return to service.
It is imperative that the proper equipment is ordered the first time. Mobility considerations and handicap-friendly buses are the best options for resident movement. The remaining wheelchair-dependent residents were evacuated by wheelchair transport vans, which can take three to four people at a time. Unloading the evacuees at the shelter site was another aspect that was not considered at the time. Contracts should be in place for transportation services and for onsite fuel services either through the facility to be evacuated or through the fire department.
Communication. Communication is always in need of improvement at large and multijurisdictional events, especially at this one. Because of the power failure, the fire department could not communicate over the public address system, so residents had to be told to evacuate face to face. The Concord employees were using store-bought handheld radios, so the fire department could not communicate with them. The private ambulances called to the scene to assist did not have any portable communication. The medical unit leader designated a private ambulance provider as a liaison. She made a list of the cell phone numbers of the private ambulances that had responded. Thus, the unit leader was able to keep track of these resources.
Scene control. Scene control is imperative and must be planned well in advance. The issue in the Concord evacuation was not spectators or a preservation of a crime scene, but staircase use. Initially, everyone was using the middle staircase, the most commonly used stairwell during normal business hours. However, the backlog of people ascending and descending with patients and equipment caused quite a traffic jam. In addition to the foot traffic, a separate group was attempting to string rope lights up the stairwell to provide lighting. Lobby command was created, and a chief officer was put in charge of the stairwell traffic.
Establishing a mass-casualty evacuation protocol under the national incident management system (NIMS) for unified communications would have placed all inoperable radio frequencies in one location to allow better communication among the public and private agencies.
Medications. Elderly people are often prescribed multiple medicines, many of which are for chronic conditions and cannot be skipped. Some seniors in the building use the supportive living services. Those who take part in that program have medication boxes. Certified nursing assistants (CNAs) administer the medications, which are kept in boxes in the resident’s room and labeled with that person’s name. The other residents self-administer their medications. Most do not keep them in a single location and do not have them split up by day of the week for ease of use. Therefore, for planning purposes, consider offering a public education program for patients and caregivers/nurses to keep a list of their medications or an emergency medicine supply on hand. If this isn’t an option, then the facility should keep such a list, but it is imperative that the list be updated and accurate.
Patient accountability. Tracking patients was difficult. First, the fire department had difficulty keeping track of those who had self-evacuated. Some residents had left the scene with family; others had gone out for the day and had not returned yet. The next issue was keeping tabs on the rooms as they were evacuated. Initially, residents were removed according to the priority system. Then the plan changed to a top-down approach. The medical unit leader kept track of those transported by ambulance to hospitals or the shelter facility. The Concord staff kept track of the others transported by bus because they went to multiple hotels. At the end, all of the numbers were compiled to ensure accountability. It is imperative in planning to use one system and that one person document the movement of people to ensure accuracy. The building census must be accurate, and systems that can provide accurate numbers of residents in the building on a moment’s notice must be in place. Under the NIMS structure, the documentation unit could have assisted with tracking the evacuees.
Resources and equipment. When planning for an evacuation of a building such as this, it is important to know your available resources. This list must extend beyond the fire department resources available through mutual-aid agreements. Although the assets are hugely helpful, they are not the only ones available. In Illinois, there is an association of private ambulance services that will provide basic and advanced life support ambulances for emergencies. Although this group was not used in this event, it would have been an asset if other responding fire departments were busy and unable to respond.
The scope of the incident exceeded the ability of the local office of emergency management to provide equipment at a scale needed for this size building. Another asset available is the Illinois Department of Homeland Security (DHS). DHS has contracts in place with generator companies, heating-ventilation-air conditioning (HVAC) contractors, electricians, bus companies, and other resources. During the evacuation, a state DHS representative arrived on scene; from that point, DHS was involved because of the number of resources used on the incident. This was a third-level Mass Casualty Box Alarm and a Second Alarm Fire Box. There were 30 departments and nine private ambulances from one company on scene. DHS met with the fire department and the division chiefs in the days after the incident. They stated that they had contracts that would have been able to bring a semitruck-sized electric generator to the scene. They also would have been able to provide enough HVAC services to handle the entire building. Had the fire department known the capabilities of DHS, the entire evacuation could possibly have been avoided.
The building owners learned the importance of maintenance, testing, operating, and recordkeeping of emergency systems (e.g., generators and batteries in the emergency lighting systems). Finally, the importance of preplanning, training, and simulation exercises for this type of event cannot be exaggerated. The exercises could be a tabletop or full-scale exercise and should include all possible responding agencies.
Three fatalities occurred in the week after the evacuation. All three were residents considered frail elderly. Each had multiple medical conditions and limited mobility. Although there is no direct link to the evacuation itself, it is possible that the stress placed on these residents may have aggravated their chronic conditions and contributed to their deaths.
Endnotes
1. Bacon, C. A. (2006). “Maximizing for Victim Evacuation & Recovery in Mass-Casualty Incidents.” Professional Safety, 51(10), 48-51.
2. Rosenkoetter, M. M., Covan, E., Cobb, B. K., Bunting, S., & Weinrich, M. (2007). “Perceptions of Older Adults Regarding Evacuation in the Event of a Natural Disaster.” Public Health Nursing, 24(2), 160-168.
3. Hyer, K., Polivka-West, L., & Brown, L. M. (2007). “Nursing Homes and Assisted Living Facilities: Planning and Decision Making for Sheltering in Place or Evacuation.” Generations, 31(4), 29-33.
4. Nomura, S., Gilmour, S., Tsubokura, M., Yoneoka, D., Sugimoto, A., Oikawa, T., & Shibuya, K. (2013). “Mortality Risk Amongst Nursing Home Residents Evacuated after the Fukushima Nuclear Accident: A Retrospective Cohort Study.” Plos ONE, 8(3), 1-9.
5. Christensen, K. M., Blair, M. E., & Holt, J. M. (2007). “The Built Environment, Evacuations, and Individuals with Disabilities.” Journal of Disability Policy Studies, 17(4), 249-254.
BRENDA K. FARLOW, NREMT-P, an 18-year-veteran of the fire service, is a firefighter/paramedic and acting lieutenant for the Northlake (IL) Fire Protection District. She has bachelor’s degree in fire service management from Southern Illinois University and is a graduate of the Loyola University Medical Center paramedicine program. Farlow is completing a master’s degree in emergency and disaster management at American Military University.
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