The United States Centers for Disease Control and Prevention (CDC) reports there are well over 15,000 nursing homes in the United States, with 1.7 million licensed beds and more than 30,000 residential care facilities with another 1,000,000 licensed beds.1 Fires and other major emergencies at nursing homes can present serious challenges to emergency responders, particularly if they haven’t planned or trained for these situations. Nursing homes are occupied by a number of people who, in an emergency, are likely unable to escape or will have great difficulty escaping on their own and have other health issues such as respiratory or cardiac problems that can be made worse during an emergency incident.
Access to some sides of the nursing home building can be limited because of the property layout, adjacent or adjoining buildings, or vehicles present to service the building. If departments have prepared well at the nursing homes in their district, a fast and efficient response may allow firefighters to safely protect the maximum number of occupants. However, an unprepared response can result in serious risks to both firefighters and the nursing home occupants. Fire departments must be aware of the various types of nursing homes in their coverage area, what hazards are present in these occupancies, and how to best respond to incidents in them.
Where’s The Fire?
Initial responders and incident commanders (ICs) need to understand their options at these facilities and realize that performing rescues will consume a significant amount of resources. Unless occupants are mobile or semimobile, it will probably take at least two firefighters to move each victim to the exterior of the building. This becomes more staffing intensive the larger the occupant is. Effective rescue operations can easily require 20 or more firefighters-an entire alarm’s worth of personnel in most areas. Victims need to be moved to either a safe place of refuge in the building or to a triage/patient collection area on the exterior of the building. Patient beds that roll can help, but they will get clogged up in hallways and exit doors. Rescue “sled-like” devices can help departments with minimal staffing move victims, but these have to be available either in the facility or on the apparatus during a response to nursing homes. Weighing the resources needed to perform rescues vs. those needed to contain and extinguish the fire often dictates that the second option is much more effective and efficient with the initial arriving resources.
Patient rooms: There are several common locations for fires to start in nursing homes, and the most obvious is in a patient room. To protect the rest of the occupants in the building, the fire needs to be contained in the patient room quickly. It is critical that the door to the room be closed until the engine crew is prepared to enter to make an attack. The engine company needs to quickly get to the fire room to keep the fire from spreading. In a perfect situation, as the engine crew prepares to enter the fire room, a ventilation crew opens the exterior windows, if they haven’t already broken out. Positive pressure ventilation may be used to pressurize the main corridor to reduce smoke and heat extension from the fire room to the hallway. As quickly as possible following extinguishment, try to get the fire room door closed to continue to contain the spread of residual smoke and heat.
Kitchen/dining area: The kitchen/dining area is a common location for nursing home fires to start. If this area has good fire separation from the rest of the facility, there is a reasonable chance that this fire will not spread throughout the building. However, it is likely to give off a great deal of smoke, and patrons/kitchen personnel may be reluctant to evacuate the area unless they perceive that the situation is truly perilous. Be prepared to make a quick attack to confirm that the fire is out, implement high capacity ventilation, and remove possibly unwilling occupants. Close doors that connect to other areas of the nursing home to isolate the problem. Check for vertical/horizontal fire spread via kitchen ductwork, even to the roof area. Be sure to understand in advance your best access to the kitchen area: Is it through the front door or perhaps a side or rear door?
Laundry: Laundry areas are also locations where fires are likely to occur. Dryers in particular can be a culprit. Like kitchen fires, if the building design works correctly, there is a reasonable chance that this fire will not spread throughout the building. However, it also is likely to give off a great deal of smoke, and workers may be present in the area attempting to control the fire. Anticipate searching for overcome employees in the area. Laundry areas may only be accessible from the rear or lower levels of a building, and you will need to figure out how to access this area. Like kitchen fires, be prepared to make a quick attack and implement high-capacity ventilation. Close doors that connect to other areas of the nursing home to isolate the problem. Check for vertical/horizontal fire spread via dryer ductwork, even to the roof area.
Lounges/common areas: Most nursing homes have one or more of some type of lounge/dining area. There is the potential for numerous victims needing to be rescued here, and firefighters must be prepared for this. Numerous powered scooters may be in these rooms, as these may be the way more mobile patients get around the facility. Victims in these spaces may not be able to be quickly isolated from heat and smoke and will need to be rescued/moved to a place of refuge or to an exterior triage area.
Attics/roofs: Some nursing homes may have attics that are of combustible construction and foster fire spread. Those built under older building codes are likely “stick-built” with 2 × 4 rafters and may not have sprinklers or firestops. Roof construction can vary from plywood and asphalt shingles to plastic/fiberglass-type insulation that can require large numbers of personnel to vertically ventilate. Those built under newer codes are likely to have lightweight truss construction but may also be sprinklered and provided with some type of firestopping. It shouldn’t be surprising to find some of the buildings equipped or retrofitted with solar panels on the roof. The only way you will know is by getting out to look at these buildings.
Hazardous materials (hazmats) are typically limited in nursing home environments. Cleaning chemicals are common, and fuels are likely used for heaters/boilers and emergency generators. The most common chemical in nursing homes is oxygen. Oxygen may be used for patients, piped through the building, and stocked somewhere on site either in small tanks or a large tank feeding a piped system. Although oxygen itself does not burn, it is an oxidizer that will considerably enhance the burning of other materials. There should not be significant amounts of other hazardous materials in a nursing home, but only preplanning will reveal this.
One major obstacle that responders face in nursing homes is the inability of the residents to self-evacuate. It is likely that the facility’s emergency plan is to protect residents in place vs. evacuating them. Often, particularly on off shifts, staffing is limited to do little more than to shut hallway or room doors to contain heat and smoke. It is certainly credible that firefighters can arrive at a nursing home facility and find that all occupants are still in the building.
They need to be in a safe location, although this may mean staying in their room initially. Elevators, where provided, will need to be controlled for emergency use. Moving victims outside can be more difficult in foul weather if an alternate evacuation location has not been identified. Victims with dementia or other similar afflictions may be mobile but incapable of making rational decisions in an emergency. They will need to be monitored to ensure that they don’t attempt to reenter the fire area or simply walk off the property.
Coordination with facility staff and emergency medical services (EMS) is crucial to control this. Conducting a preplan with EMS is crucial so that avenues to move patients and triage areas that make sense to all are clearly identified up front and during the incident. Triage areas may be planned outside of the building, but there may be locations that are segregated inside of the building that can be set up for this also; again, these must be planned in advance. Understand that fire apparatus and hoselays can very quickly limit access and egress from the scene for EMS vehicles; coordination is crucial.
Many nursing homes are sprinklered. Protection will likely be a wet-pipe system, although dry-pipe systems may be used for attics or top floors in cold climates. The sprinkler system may be combined with a standpipe system as well. Supplies for these systems can vary significantly, depending on where the nursing home is located. Those in rural areas may have very limited water supplies. Operations necessary to support these systems include ensuring water supplies are operating effectively; keeping valves supplying the operating system fully open until the fire is extinguished and the IC determines it’s appropriate to turn the system off; and ensuring any fire pumps are operating properly.
Firefighters with radios should be stationed at each valve supplying the operating sprinkler system until full extinguishment of the fire is confirmed-even after the fire has been controlled. This ensures that the sprinkler supply valves are not closed inadvertently and that firefighters can reactivate them should a fire suddenly rekindle. (See “Firefighting in Sprinklered Buildings,” September 2013 FireRescue, for more information on operations in sprinklered buildings.)
It is critical that one of the first-arriving engine companies pumps into the sprinkler/standpipe connections to ensure adequate pressure is available to this equipment. A tanker/pumper backed up by a more sustained water supply might be needed to perform this function for nursing homes located in areas with limited water supplies. Connect lines to the fire department pumper connection on the system and supply them at the designated pressure (if the designated pressure is not known, pump at 150 psi). This pumping operation should continue until the IC determines it’s appropriate to stop. Some locations may have numerous sprinkler systems and therefore numerous fire department connections that may or may not be interconnected. Clues to which system is operating, and thus which system fire departments should connect to, include an operating water motor gong above or next to the connection and water discharging from the main drain line below or next to the connection. However, these clues don’t always identify the correct connection. Identify the proper connections by surveying the building before the fire and clearly marking the correct ones, as well as identifying the water supplies needed to fight a fire in these properties.
Nursing home kitchens are likely to have wet chemical discharge systems over the cooking areas. There may also be specialty systems, such as gaseous suppression systems, protecting nursing home computer and phone system control rooms. While the systems should be designed to operate automatically in a fire, there is the potential that the systems have not activated on the fire department’s arrival, and a decision must be made to manually activate the system if it is the best means for handling the incident. In any case, it is important to allow the system to do its job. Wear breathing apparatus when entering areas protected by these types of systems when an incident is in progress.
Nursing home phone or computer rooms may also be provided with an early-warning smoke detection system that will require your best investigation skills to determine why the system has alarmed. These systems sample the air in the protected area and can detect invisible smoke particles that may result simply from wiring beginning to overheat. Thermal imaging cameras and good detective work are needed to check the entire protected area to determine if a fire may be in a state that is essentially preincipient. Survey the building in advance to understand why these systems are there and how best to use them at an incident.
Fire departments always need to consider the ability to advance hoselines to all areas of a nursing home. If nursing homes are equipped with standpipes, hose packs of appropriate length and diameter should be carried to attack a fire in any area of the nursing home. Hose used in standpipe packs should be at least 1¾ inches in diameter, but firefighters may want to consider larger diameter hose such as two inches or 2½ inches, particularly if the nursing home is of moderate or large size, unsprinklered, or of combustible construction. If standpipes are not provided, apparatus need to be equipped with attack lines that can reach any area of the nursing home, or be prepared to extend hoselines into the fire area using two-inch, 2½-inch, or larger lines.
Ladder Ops and Ventilation
Ladder company functions can be eased at these incidents by various building features. In multifloor nursing homes, stairways or access ladders can lead to roofs, and these can be used to vertically ventilate the building. However, identifying which stairs have roof access needs to be preplanned. Take care that ventilation using stairways is done after victims are removed, unless the tactic is employed specifically to clear the stair tower so occupants can use it to exit and it is coordinated with the rescue teams. Depending on the type of nursing home, exterior windows may be sealed shut. A determination must be made as to the necessity and safety of breaking the windows for ventilation purposes. Some windows may be designed not to break, while others may have been designed to work to allow firefighters to “push” them in from the outside. Again, it is important to identify this in advance. If the building has a smoke control or evacuation system, it should be trained on and assigned to a specific firefighter/officer to operate during an incident.
Truck companies may need to work hard to get a good position to effectively use their aerial devices. A corner of the building can be an excellent location (so two sides of the building can be “scrubbed” by the aerial), or the truck may have to be driven onto the lawn or up a path to get it in a position that will allow the aerial to be brought to bear on as much of the building as possible.
Facility access can be a challenge in nursing homes. Often exterior doors have some type of locking mechanism to prevent occupants from leaving on their own, particularly at memory-care facilities. Patients will often have some type of bracelet that causes the door to lock when they get near it. While this should be overridden by the fire alarm system activating, during a fire nothing is guaranteed. Understand how the system works in advance, determine how it will work in an emergency, and continue to check this over time as modifications can be made to these systems.
A Final Note
As with most other types of occupancies, the most important thing a fire department can do to prepare for nursing home incidents is to preplan the buildings. Do not fail to start this process during the design/construction phases of any new nursing homes being constructed in your response district. We are seeing more of these being built lately, particularly memory-care facilities.
At all nursing home incidents, dealing with life safety issues will be the overriding concern for the IC, but lives may be best saved by putting the fire out instead of using limited initial resources to perform multiple rescues. Be sure that the nursing home staff meets up with you (and stays with you) on arrival to assist in providing occupant lists and guiding your response. Think beforehand about how hoselines can be advanced to all the potential areas in the building, and be sure that your apparatus is set up to accomplish this. Quick, effective action will save lives.
1. Centers for Disease Control and Prevention. “Nursing Home Care,” 2014, www.cdc.gov/nchs/fastats/nursing-home-care.htm.