The fire alarm blares as the nurse wonders whose dinner is burning in the microwave. The nurse turns the corner to find the hallway banked with thick, black smoke from ceiling to floor and hears patient cries for help. Will the nurse know what to do? Without emergency preparedness, the best response will depend on the nurse's current knowledge and skills for fire management. Initial decisions are critically important—they determine if the recovery phase includes a period of care disruption until facility operations return to normal or the tragic outcomes of caring for the injured, accounting for missing persons, or body recovery.
Facilitation of emergency preparedness can be a daunting organizational objective. In this article, the US Department of Homeland Security's Ready framework is utilized for emergency preparedness planning, education, and evaluation at a long-term-care facility using fire as an exemplar.
Fire is a chemical reaction between fuel, oxygen, and heat. Many of today's buildings contain synthetic materials, which burn hot and produce toxic smoke such as hydrogen cyanide and carbon monoxide.1 Inhaling toxic smoke can impair gas exchange, affecting consciousness and coherent thinking abilities. Temperatures can reach 100° F at floor level and 600° F at standing eye level.2 The moment a fire starts, patients and staff are at risk for injury, including smoke inhalation, burns, and physical and emotional trauma.2
Between 2011 and 2015, US fire companies responded to an estimated annual average of 5,750 healthcare facility structure fires. Forty-eight percent of these fires occurred in long-term-care facilities, causing 1 fatality and more than 100 injuries. Three percent of long-term-care facility fires spread beyond the initial room of origin; cooking equipment was implicated in 68% of these fires, causing 28 injuries.3
Fire is a no-notice incident requiring immediate decisions by the person who makes the discovery. Staff members must be able to communicate an emergency plan; account for patients and staff; and coordinate procedures for full facility, horizontal (moving within the same floor level to a connected area), or vertical (moving to an area below the impacted area) evacuations or sheltering in place.4
Compounding fire management are false alarms, causing poor resource use.5 Fire alarms may also contribute to complacency by ignoring the alarm or thinking it's a nuisance rather than a stimulus requiring prompt action.6,7 Moving from complacency to engaged behavior involves identifying an individual's value perceptions and addressing the importance of emergency preparedness. Long-term-care facility staff members provide care for vulnerable populations; accounting for patients and personnel in the initial moments of a fire incident is critical to directing resources. Staff members need to facilitate initial rescues; once on the scene, firefighters rescue trapped individuals and extinguish the fire. Ability, time, and readied available personnel are limited resources during a fire to achieve the goals of saving human life, minimizing property losses, and supporting the facility's stability to provide and maintain care for patients.
The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) have consistent requirements for healthcare worker emergency preparedness: 1. Healthcare administration conducts regular assessments to determine all-hazard incident risks. 2. The facility's required emergency operations plan addresses all-hazard incident risks and includes regular updates. 3. Incident command manages all-hazard incidents. 4. Education and evaluation programs are in place for regular testing and updates relating to personnel competencies.8-12
All-hazard incidents include fires, natural weather events, infrastructure failures (computer, phone, power, or water), mass casualty incidents (intentional violence or infectious), and hazardous chemical or radiologic incidents.2 A hazard vulnerability assessment is initially conducted to determine the facility's all-hazard incident risks before development of the facility's emergency operations plan and then regularly performed to update the plan.13 This assessment includes internal all-hazard incidents that may occur within the facility and external all-hazard incidents that may occur outside the facility but impact it.14
Incident command is a comprehensive integrated management system used among agencies to ensure responder safety and manage resources utilizing consistent role, language, and responsibility structures during all-hazard incidents.14 Many agencies respond to an all-hazard incident, such as a fire in a long-term-care facility. Interagency use of incident command as a flexible, scalable tactic aids clear, effective communication to operationalize emergency plans and achieve the best outcomes during incident response and recovery.
Emergencies and disasters have timeline phases—planning and preparedness, response, and recovery—that coincide with emergency operations plan needs and benchmarks, and response and recovery guidelines.2,13,14 Easing the impact of all-hazard incidents requires that a facility assesses its risks, determines what resources are available and how these resources will be mobilized, and ensures personnel readiness. The Department of Homeland Security's publicly available online education program called Ready can be used to plan, educate, and evaluate long-term-care facility emergency preparedness.2 (See Table 1.)
The Ready framework's first step is “be informed.”2 A fire incident will change the day-to-day operations of a long-term-care facility into a complex situation. A principle of incident command is that the first person on the scene is in charge until the arrival of experts or more senior leadership. For example, a staff member who discovers a fire will relinquish command to the charge nurse when he or she arrives. The charge nurse then relinquishes command to facility administration and community partners (fire, emergency medical services, and police) once they're on scene. The use of incident command role names, consistent responsibility structure, and language enhances efficient command transfer.
Staff members and administration need to be informed of their emergency operations plan roles and what they're expected to do. This requires all-hazard incident emergency preparedness education. Clear learning objectives delivered in a predictable sequence help engage staff and build emergency response behaviors/skills. Classroom tabletop exercises and drills are designed for staff members and administration to problem solve and then demonstrate the use of the facility's emergency plan and procedures.2 (See Table 2.) Procedures may include using a fire extinguisher for a cooking equipment fire or how to evacuate a bed-bound patient down steps. Plan applications may include using facility accountability procedures in a full facility evacuation. The ultimate outcome of being informed is prepared healthcare personnel ready to act rather than waiting for someone to tell them what they need to do or how to do it.
Make a plan
The second step—“make a plan”—addresses life safety issues for patients, staff, and any person in the facility.2 For example, a documented process to determine who's in the building and their location after an evacuation if a fire occurs is needed. Ideally, plans describe personnel roles and provide guidance for the general operations of accountability, communication, and coordination.9,11 Procedures are usually used to mobilize facility resources and operations by personnel during all-hazard incidents. The CMS' Emergency Preparedness Rule includes a disclosure decision tool to address Health Insurance Portability and Accountability Act regulations for notifying family members or responsible individuals in an emergency.11 In addition, facility plans need to address on-shift emergency communication between personnel, family members, and significant others.
Involving staff members in making the plan may reveal the possible difficulties of real-time implementation. These gaps can inform next-step needs for education, plans, policies, or procedures. For example, a fire incident may require changes to roles or procedures due to staff-to-patient ratios during different time periods, such as day shift versus evening or night shifts. The plan should include two common healthcare fire safety acronyms: RACE (rescue, alarm, contain, and extinguish or evacuate) and PASS (pull the handheld fire extinguisher pin, aim at the base of the flames, and squeeze the trigger, sweeping the nozzle back and forth).15
Build a kit
“Build a kit,” the third step in the Ready framework, transfers plan resource coordination to staff and patient actionable behaviors.2 Key to patient safety during an evacuation is having available supplies and information for receiving healthcare providers at patient collection sites, shelters, and/or planned alternative healthcare sites. Paper information forms can prove a challenge to keep updated but are vital if computerized information sources are unavailable. Supply kits, such as a bedside carryall, and larger durable assistive devices, such as wheelchairs or walkers, should be in consistent locations so they're readily available.
The carryall kit contains a flashlight; batteries; patient care and equipment supplies; and, if not in use, patient footwear, eyeglasses, dentures, and hearing aids. If ambulatory patients have no footwear, manpower and equipment will be needed to relocate them if the environment or terrain is unstable from debris or damage.16 Safeguards to patient care include health and functional ability histories, a current medication list, and communication/permission contact information for family members, significant others, or legally responsible decision-makers. A periodic inventory of the basic supply kits is important to make sure included items are current, appropriate, and built for new patients.
The last step is “get involved.”2 This step is essential for staff confidence and patient trust that facility-specific issues are addressed through staff education and demonstrations during evaluated tabletop exercises and drills.
Tabletop exercises and drills provide practice experiences for staff to use fire management knowledge. Engaging staff members in simple procedures, such as RACE to identify who moves first or PASS to demonstrate using a fire extinguisher, builds confidence to test parts of the plan in more complex scenarios. Building the use of skills from simple to complex may be accomplished by having personnel evacuate different patient types: uninjured ambulatory patients, uninjured mobility-dependent patients, and then injured patients.
Next, conduct a unit vertical or horizontal evacuation and then demonstrate a full facility evacuation with incident command roles and accountability procedures. The time and resources needed to move people are the greatest limitation during an evacuation.4 A fire incident is never the time for figuring out how to implement the plan, how long it will take, or the resources needed to conduct a unit or full facility evacuation.
Getting involved and staying involved requires staff development with a focused priority on life safety. Involved staff members are informed with the knowledge, skills, and abilities to be ready for different needs during different shifts, as well as when at home. Staff readiness when at home requires plans for themselves, their families, and significant others.17 If off-shift staff plans don't exist, staff members may not be available to report or stay. This may affect patient care if there are low staff and high patient ratios at fire evacuation collection sites or if patients are transferred to alternative care sites. Getting involved also applies to patient family members and legal decision-makers so they're aware of procedures for removing a patient from the evacuation collection site to a home residence.
When healthcare providers are prepared and know what to observe for, they can more readily identify psychological distress. Patients may experience distress because the long-term-care facility is home to them and they think of staff members as extended family. Staff members may experience distress if they think of coworkers as family or fear their livelihood is at risk.
Preventing the predicable
Emergency preparedness builds readiness to prevent what's predictable during an all-hazard incident. Without a plan and practice, life safety is at risk. The idea of “drilling until you fail” is critical because fires seem to come from nowhere and each incident is unique.16 Exercises and drills aren't a panacea that future incidents will have only the best of outcomes. However, every use of plan knowledge or a procedure skill may aid transfer of better decision-making abilities during a fire or other all-hazard incident.
The Ready framework steps provide an approach for staff in long-term-care facilities to develop emergency preparedness. If a facility fire were to occur, staff members who are informed about the facility's emergency operations plan and familiar with incident command practices; have basic supply kits ready for evacuation or to shelter in place; and are actively involved in education, exercises, and drills to determine facility and staff strengths and challenges will be better prepared. Staff would then be able to communicate vital information, account for patients and staff, and coordinate procedures in the critical moments until additional help arrives. Efficient staff response during a fire incident garners transfer of basic emergency preparedness abilities to other all-hazard incidents, such as natural weather events or infrastructure failures, using the facility's operations plan.