By MICHAEL KENNEDY and ARIC D. ALEXANDER
The United States Census Bureau reports that there were 36.8 million people 65 years of age and older in the United States as of July 1, 2005, and that senior citizens accounted for 12 percent of the nation’s population. Between 2004 and 2005, this age group grew by 457,000. EMS providers are affected by this demographic daily, but its effect on fire operations should not be overlooked. As this population shift continues, so will the demand for housing that meets the lifestyle demands of active senior citizens and those in need of much more advanced medical care. According to the National Fire Protection Association (NFPA), once a person reaches age 65, the risk of being killed or injured by fire doubles in comparison with the general population.
Many communities are seeing a building boom in senior care housing that is much different from that of a generation ago, which more resembled a sterile hospital environment. Many of these new facilities have senior citizens with very different needs all living at a facility that might possess a single street address. It is only through thorough preplanning that fire departments will be able to identify these occupancies and establish appropriate rescue and fire suppression strategies.
TYPES OF FACILITIES
Below are some terms with which fire service personnel should be acquainted.
The living units may be condos, apartments, or townhouses where seniors live with minimal or no supervision. Many of these seniors still drive vehicles and live active lifestyles. Some facilities have a button or pull cord in each unit that the resident must activate each morning to indicate he is okay. If a unit is equipped with such a feature and the resident does not “check in” by a set time, a staff person may call or visit the unit to check on the resident’s status. This may be the only staff/resident interaction that occurs within a 24-hour period. Busy EMS units may be able to set their watches by the regular medical dispatches that accompany these checks. Independent living units have layouts and amenities similar to those of regular apartments or condos. Some independent living communities have no regular staff interaction other than that of facilities maintenance personnel.
The population living in these facilities is ambulatory and able to perform daily hygiene routines. A standard difference between assisted and independent living is the inclusion of on-site dining facilities. Staff may assist these residents with items such as medication administration, and check-ins are more frequent.
These facilities may include “a building or a portion of a building used on a 24-hour basis for housing four or more persons who are incapable of self-preservation because of age; physical limitations due to accident or illness; or limitations such as mental retardation/developmental disability, mental illness, or chemical dependency,” according to the 2006 edition of NFPA 101®, Life Safety Code® (LSC), Section 220.127.116.11.
Long-Term Care (Dependent Living/ Skilled Nursing) Facilities
Occupants may include “residents ranging from ambulatory to ventilator dependent or who because of mental or physical incapacity might be unable to provide for their own needs and safety without the assistance of another person” (2000 edition of NFPA 101®, LSC®, section 3.3.132). Medical staff may range from medical assistants to an on-site physician. Usually, one nurse will always be on duty, but the nurse-to-patient ratio may be extremely low, especially during night shifts.
Regardless of the type of living situation, a senior citizen may be fully lucid but still be a victim of deteriorating physical health. Additionally, residents within any of theses categories may have cylinder or inline oxygen supplies in their living unit. Cylinders may range from a normal “E” size (680 liters/24 cubic feet) up to an “H” size (6,910 liters/244 cubic feet). They might be found in some or all resident rooms. Another common method of oxygen delivery is the oxygen concentrator. It is similar in size to a suitcase and is generally used outside of the home or during a power failure; it contains an internal pump and a battery. Yet another system for delivering oxygen is piped-in medical gas. Piped-in medical gas outlets will be located in the resident or patient room; shutoff valves are in the corridors on the floor or floors where the piped-in oxygen is used. Refer to the 1999 edition of NFPA 99, Standard for Health Care Facilities, Chapter 4, for specific piped-in gas and vacuum requirements.
A growing trend is to build one large facility that can accommodate all four groups. This is especially common with Alzheimer’s patients, for as residents become further debilitated by the disease, they may be able to be moved to another section to meet their needs while maintaining similar surroundings. Alzheimer facilities can pose forcible entry dilemmas because of efforts to contain patients. Key lock box systems work very well if such exit-control methods are present. Under drastic situations, a physician may order a patient to be restrained to a bed. Firefighters must be aware if the practice is occurring in case a total evacuation is ordered. Additionally, patients found to be restrained to a bed without a physician order should be followed up on through appropriate senior-abuse channels.
All senior facilities ideally should be protected with monitored alarm systems including smoke/heat detectors, sprinkler systems, smoke dampers, automatic door closers, and standpipe connections, if multiple stories. Firefighters must know the locations and functions of annunciator panels, fire department connections, and standpipes, if so equipped. Because of the size of these buildings, it is not uncommon for there to be one functional master annunciator panel [i.e., fire alarm control panel (FACP)], with separate view-only annunciators (remote annunciator panels) that may be near nursing stations or staff offices.
Compartmentalization is one of the key safety components of these buildings. Depending on the building’s construction, compartments can vary from individual living units to subdivisions of floors to entire floors. You can easily identify floor subdivisions by the location of fire doors in hallways. Because of compartmentalization, complete building evacuation is often contraindicated in these facilities.
Shelter in place, or defend in place, is a common strategy used regardless of building sprinkler status or building construction types, since these requirements vary according to the year of construction. At face value, this seems to go against normal fire service doctrine. However, one of the factors that makes the senior demographic susceptible to fire death is limited physical mobility. It is not a secret that attempting to move a large number of seniors takes significant time and resources. To be able to use the shelter-in-place strategy, senior units should have 20-minute rated fire doors or equivalent (2000 edition of NFPA 101®, section 18.104.22.168) between the individual units and common corridors.
Unless the fire is in their unit, seniors should be taught to shelter in place in a fire and not to evacuate unless firefighters direct them to do so. If the incident commander decides to evacuate, horizontal evacuation through smoke barriers (one-hour fire-rated assemblies with properly sealed “smoke protected” openings such as doors and HVAC ducts) is usually preferred. Many seniors may be physically unable to walk down stairs to vertically evacuate; if they try, they might exacerbate a medical condition that may be a worse threat than the fire.
Fire departments should take a three-tiered approach to prepare for fires at these facilities.
Fires at senior living facilities present unique challenges that will quickly present more operational tasks than first-alarm companies can handle. Failure to assign enough companies early on will result in the incident commander’s playing a futile game of catch-up throughout the fire. Any reported working fire at a senior living facility should be automatically upgraded to a full second-alarm assignment. It is critical that first- and second-alarm companies be specially trained on senior living facilities.
(1) Fire companies should have additional companies (a second-alarm assignment) prearranged for any reported fire at a senior living facility. (Photos by Mike Kennedy.)
Preplanning senior facilities will save lives and prevent initial companies from becoming overwhelmed. In the immortal words of the late Chief Tom Brennan, “If you put the fire out, your problems tend to go away.” Routinely, the most effective way to save lives when faced with a senior facility fire is to quickly extinguish the fire. The standard preconnect will seldom be appropriate at these facilities. Fire companies must measure for the required hose stretches. Variable length hose loads (300 to 500 feet of 2 1/2-inch hose with a gated wye connected to 150 to 200 feet of 1 1/2- or 1 3/4-inch hose or a standpipe pack if the building is so equipped) may work well. As with all fires, ventilation is a key component. Crews must be very deliberate to try and prevent smoke from the fire floor from traveling to unaffected areas. Using positive-pressure ventilation to pressurize the stair towers and fire floor can be very effective in controlling smoke migration.
On-site staff will mainly be found at assisted-living and long-term care communities. A strong ally that local fire departments have relative to fire safety at senior care facilities is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). On a very basic level, JCAHO is to the health care industry what the NFPA is to the fire service. According to JCAHO, it “evaluates and accredits nearly 15,000 health care organizations and programs in the United States.” For a facility to maintain JCAHO certification, it is subjected to a site survey at a minimum of every three years. JCAHO maintains that its proactive process assesses Life Safety Code® compliance (JCAHO Statements and Conditions, part 3), which references NFPA codes including NFPA 10, Standard for Portable Fire Extinguishers; NFPA 13,Standard for Installation of Sprinkler Systems; NFPA 72, National Fire Alarm Code®; NFPA 99, Standard for Health Care Facilities; and NFPA 101®.
(2) Preplans of senior living facilities should include the locations of fire department connections and annunciator panels.
The Centers for Medicare and Medicaid Services (CMS) have a part in health care regulation, as do the state agencies for long-term care and other facilities involved in the Medicare and Medicaid programs. For long-term care facilities, an annual fire safety inspection is conducted in accordance with federal and state requirements. Facilities such as hospitals and other health care facilities are inspected for fire safety compliance on an annual basis, using codes and standards adopted by the state. For example, Michigan conducts annual inspections of all regulated health care facilitieshospitals, nursing homes, adult foster care facilities, homes for the aged, free-standing outpatient surgical centers, and ambulatory surgery centers. Part of this site survey is a detailed review of the facility’s fire safety policies, procedures, alarm and suppression systems, as well as overall fire safety compliance in accordance with applicable codes and standards.
(3) Fire companies must estimate and train on hoseline stretch distances for senior living complexes.
Depending on your department’s staffing, having fire department personnel assist with new employee training and annual refreshers can make fire operations go much easier. This is a great opportunity to educate the staff and get them onboard with the needs of the fire department. Some facilities may have accountability systems for residents and staff that may be priceless during a fire. You should identify these items during training and decide how facility personnel will operate within the incident command system (ICS). In accordance with the National Incident Management System (NIMS) model, facility management could be integrated into the ICS through the liaison officer. However, a preferable position is within a unified command. Facility management may be the sole resource for information on residents and the building, and this information will assuredly affect the incident action plan. Facility management personnel should be briefed on the fire department’s incident command system and how they can be of substantial benefit to the fire department. They should be briefed on the fire department’s ICS and encouraged to complete FEMA’s online training courses.
Shelter in place is a foreign concept to most seniors, so educate residents on what do to and what not to do in a fire. Again, this will be site specific. Fire companies should participate in fire drills to further build strong relations with staff and residents. The United States Fire Administration (USFA) and the NFPA have excellent fire safety programs tailored to senior citizens that can be incorporated with site-specific information. Some cursory benefit to senior fire safety education is that according to the U.S. Census Bureau, 71 percent of seniors reported that they voted in the 2004 election. This is a higher percentage than any other age group. Thus, having a large group of fire safe seniors with a positive impression of the fire department can be a valuable resource for any fire department when dealing with municipal budgeting issues.
Fires at senior living facilities pose challenges for even the best trained and equipped fire departments. This is a concentration of high-risk demographics that present special hazards. However, some simple proactive approaches can ensure the safety of firefighters, staff members, and residents.
MICHAEL KENNEDY is the northeast regional coordinator for the Maryland Fire & Rescue Institute, a 13-year veteran of the fire service, and a firefighter with the Abingdon (MD) Volunteer Fire Company. He has a B.A. in political science from the University of Michigan, Ann Arbor, and a master of public administration degree from Eastern Michigan University, Ypsilanti.
ARIC D. ALEXANDER is a fire marshal inspector with the State of Michigan, Bureau of Fire Services. He is a 14-year veteran of the fire service and a firefighter with the Green Oak Township (MI) Fire Department.