FOCUS ON: HEALTH CARE OCCUPANCIES
In its 58-year history, Feather River Hospital had never been forced to evacuate. Then came the wildfires of July, 2008.
NFPA Journal®, January/February 2011
By Melissa Barnard
In late June of 2008, a series of electrical storms throughout Northern California, including Butte County, ignited what came to be known as the Butte Lightning Complex Fires. These fires burned to the end of June and through much of July. In Paradise, a town of 28,000 in the foothills of the Sierra Nevada Mountains, residents became accustomed to the constant orange-brown haze of smoke in the air. By the end of the first week of July, much of the town was threatened by the fire, and evacuations had begun.
As the third anniversary of the evacuation approaches, the author considers some of the important aspects of the hospital’s new approach to emergencies.
Evacuation is an option
After nearly 60 years of relying on shelter-in-place as our only option in a wildfire, we now know evacuation is another necessary option. The hospital may not burn in a wildfire, but the smoke can be incapacitating, and very dangerous to patients. We can also consider evacuation earlier rather than waiting until the last moment in an emergency. Drilling on evacuation procedures is essential.
The command center can move
If we’re threatened by fire, we can set up our command center in an alternate, safe site—across town at the Feather River Health Center would have been a good idea. There should be a checklist for what the command center needs, such as computer printers, extra phones, and lists of employee and patient information.
We need communication training
A lot of hospital staffers were evacuated from their homes, but we didn’t know where they’d gone. We didn’t have landline numbers for them, and it can be hard to reach people because cell phone service isn’t very good. People were unsure how to check their hospital email from home, they didn’t know about the employee hotline that was set up, and they didn’t think to check the hospital website for updates. Staff education and training on all of these points is essential.
We need department-specific disaster plans
In the event of an emergency, including an evacuation, every department’s needs and requirements are different: what to take, what to leave, what to turn off or leave on, what to lock or not, what to do with various systems. Little of this existed in 2008. We now have specific plans from all 40 departments in the hospital.
Figure out what’s essential
Our area was under an immediate evacuation order, yet hospital employees were bypassing roadblocks to get to the hospital, even though it was closed. This is psychologically taxing and just plain poor judgment. In an emergency or evacuation, we need to determine what constitutes essential services and who needs to be there, and we need to make sure policies are in place to keep all employees out of harm’s way.
Monitor employee hours
We need to anticipate that an emergency event could last a long time, and we need to pace ourselves. Instead of letting people staff the hospital command center for 16 hours or more, we need to limit shifts to six or eight hours and have backups ready to take over.
Monitor employee stress
Even with reduced hours, emergencies are still highly stressful events, and we need to make sure that an emergency plan includes stress prevention and psychological first aid. We’re developing a trained disaster mental health team that will play an active role in helping people handle stress.
More paperwork training
We’d done some training with the Hospital Incident Command System (HICS) — the forms that hospitals use that match the Department of Homeland Security system for keeping an operational log in an emergency — but we need more. This system is meant to guide our response and recovery in a coordinated way, and the more we understand how to best use them, the more successful we’ll be.
Butte Lightning Complex Fires
On June 20, 2008, dry lightning struck northern California. This lightning storm was unusual in that it covered almost every county north of the San Francisco Bay Area. It was also much earlier in the year than is typical, and wildland fuel moisture levels were at an extreme low for June. In addition, Butte County had just suffered two major fires, the Ophir Fire and the Humboldt Fire, which combined destroyed almost 100 residences. The lightning storm ignited numerous fires. In Butte County alone the storm ignited 41 fires of consequence. In all probability the storm ignited other fires, but they were soon merged into larger fires. In fact, that was ultimately to be the fate of many of the original ignitions. (From a report on the fires prepared by Butte County Office of Emergency Management for the California Emergency Management Agency. To see the complete report, visit nfpa.org/buttefire.
I’m an emergency room nurse and director of the Emergency Department at Feather River Hospital, a 101-bed facility located in Paradise. I’m also chair of the hospital’s Emergency Management Committee, the group responsible for the planning, mitigation, response, and recovery related to disasters, which is any event that disrupts normal hospital operations. The hospital conducts two emergency preparedness exercises per year, as mandated by The Joint Commission (which uses NFPA 99, Health Care Occupancies). In the 58 years that the hospital had been here, however, it had never been evacuated. In the event of a wildfire, the Paradise Fire Department had always advised us that the plan would be to shelter in place. That was about the extent of the hospital’s plan related to the threat of wildfire.
The hospital had fewer than 50 patients the first week of July, down from a typical count of 75, possibly because people were staying home due to the poor air quality. By the second week of July, we had become desensitized to the worsening conditions. We were used to working in the smoke, used to people having to evacuate their homes, used to road closures. No one was thinking about having to evacuate the hospital.
Day 1: Evacuation
Tuesday, July 8
At about 7:30 a.m., I received at call at home from the hospital. The town’s emergency operations center (EOC) had contacted the hospital to report that a precautionary evacuation had been declared for the area of town that includes the hospital, and requested that we immediately set up our command center. I got to the hospital as quickly as I could. I reported to our boardroom, which now housed the command center, and took a seat next to Wayne Ferch, our CEO and incident commander. We sent a representative to the town’s command center to ensure clear communication between the town and the hospital, and took steps to set up hotlines for the public and for employees with updates on the hospital’s status.
Outside, things were getting worse. Burning embers occasionally fell from the sky onto the property. Grounds personnel were assigned to make continuous rounds, and report back to the command center hourly. The neighboring towns of Yankee Hill and Concow, located to the east on the other side of the Feather River, where the fires were worst, were under immediate evacuation. At around 11:25 a.m., the fire department upgraded our area from “precautionary” to “immediate” evacuation status. Precautionary means it’s highly advisable to leave; immediate means authorities go door to door to make you leave. More than 12,000 people in Paradise were now under that immediate evacuation order, and reverse 911 calls from the town were alerting residents to leave as soon as possible. But the fire chief did not order the evacuation of the hospital per se. Hospital directors told staff to leave if they needed to get home to evacuate.
Even though the hospital was in the area of immediate evacuation, we had not yet made a final decision to evacuate, because we knew that such action could be harmful to patients.
Evacuations can lead to dehydration, interruption of medical/nursing care, and psychological suffering; sometimes patients can die. The state health department recommended finding accepting hospitals for all of our patients, and the county health department worked to gather ambulance strike teams to transport patients out in case we needed to evacuate. Hospital staff determined which patients could be discharged, and to where; we made arrangements with three other hospitals in the region, including Enloe Hospital in Chico, about 20 miles west, and Oroville Medical Center in Oroville, about 20 miles to the south, to determine bed status in case any of us needs to evacuate our patients. This was still all one large contingency plan, though — the plan remained sheltering in place.
At around 3:30 that afternoon, the decision was made to immediately transfer the five patients in the intensive care unit, since they would require the most arrangements and have the highest medical need. All further surgeries were cancelled for the day, and for the next. The emergency department was on diversion, meaning that ambulances would take emergency patients elsewhere, unless a patient needed immediate stabilization prior to transfer elsewhere. We would not be admitting any more patients.
As the afternoon wore on, all the outbuildings on the hospital’s campus were evacuated. The hospital’s air handlers were turned off to prevent smoke and ash from being drawn into the building. With the air handlers off, the temperature inside the hospital rose quickly, and smoke inside the building made it difficult to see down hallways. We moved our disaster trailers — which we’d received from the Department of Homeland Security in the wake of Hurricane Katrina, part of the agency’s Hospital Preparedness Program — to the parking lot of the Feather River Health Center, the hospital’s clinic located about four miles away, on the other side of town, in case we needed to set up for an alternate care site if the hospital closed. The main intersection closest to the hospital was closed. The hospital’s emergency department was still open, though, and we still had 38 inpatients. We devised a plan to keep a skeleton crew of about five of us in the command center throughout the night.
At 8 p.m. the fire chief called to tell us we should evacuate the hospital. Because we had never evacuated before, and because no emergency transfer procedure existed, we went through the process of discharging and transferring patients as we normally would, with nurses and physicians calling reports to the receiving hospitals in Chico and Oroville, writing transfer notes, and making paper copies of everything. This was very time-consuming, though, and time was a commodity we were running out of. Shortly after 11 p.m., we got another call from the fire chief that the winds were changing and that the fire threat was increasing — suddenly we needed to have every patient out by 2 a.m. Several local physicians showed up to help. Receiving hospitals told us to just send the patients, and not worry about all the usual transfer orders and paperwork. At 1 a.m. we loaded the last patient into an ambulance. The emergency department was empty.
The hospital was closed, but about a dozen hospital staffers — maintenance, lab workers, kitchen staff, and several of us manning the command center — remained in the building, along with scores of firefighters who were using the hospital as a base. We notified other hospitals and the county and state health departments that we were closed. My throat was sore from lack of sleep and the ever-present smoke. The guys from maintenance covered the hospital’s large sign with white plastic, and a smaller sign taped atop it read simply, “CLOSED.” It was hard to comprehend that what we’d always considered unthinkable had just happened.
The hallways were filled with smoke, and most of the lights were turned off. I went to the emergency department to sleep on a gurney, without much success.
Day 2: Closed
Wednesday, July 9
I got up early Wednesday morning with a strong desire to sleep in my own bed. I had been in the command center for almost 23 hours, and I decided to go home to rest. I drove to my house, only to find it empty — my family had been evacuated. I called a friend and learned that my husband and three young sons were across town at the home of another friend; my parents, who live across the street from us, were also at the friend’s place, located near the Health Center on the west side of town. (I later checked my office voicemail and found a message from my husband telling me where they’d gone. I’d been so busy in the command center that first day that I’d forgotten to call my family or check my voicemail.) I got back in my car and began driving toward the clinic. As I drove through what looked like a ghost town in the eerie haze, I suddenly began to cry. I had to suppress this catharsis, though — I didn’t want to upset the kids by showing up with tears streaming down my face. I briefly said hello, then goodbye — my husband had decided to take the kids to Yosemite for a camping trip for the next several days. Between the threat of fire and my plan to continue working through the emergency, taking the kids out of town seemed a good idea. I crawled into my friend’s guest bed and slept soundly for five hours.
Meanwhile, plans were being made to reopen the hospital’s emergency department that day by noon. Even though we were still under immediate evacuation, we simply couldn’t fathom the thought of not having emergency services available to the community. Just before noon, though, the fire department advised that we not reopen for at least two days because of the smoke, and because of the potential for more fire movement.
I returned to the hospital command center in the afternoon, and began making preparations for a possible “code black,” which was the hospital’s designation for shutting everything down and evacuating all staff. If the fire was at our door, the telephone operator and command center staff would set up across town at the Health Center. Telephones would be forwarded to that building at the last minute. Paper records for obstetric patients were kept handy in case any of our 20 potential labor patients sought care elsewhere — we would be able to get their charts to the providers right away. Command center staff was scaled down to only a few people.
Once we’d been closed for 24 hours, our business interruption insurance kicked in. Our CFO assured us it would help offset the costs of closing the hospital. It was a hopeful moment amid all the smoke and lack of sleep.
Day 3: The clinic is open
Thursday, July 10
The news early Thursday was not good. A number of smaller fires had coalesced into a large conflagration that had been named the Camp Fire, and it was devastating large parts of Concow, across the river. Fifty additional fire trucks had arrived at the hospital’s campus, part of a response to the worsening conditions. Across town, the Health Center was open, but staffers were reporting that they were overwhelmed with patients because the hospital’s emergency department was closed. Doctors and nurses from the hospital were also working at the clinic, but their unfamiliarity with the space was causing some confusion.
At the hospital, we kept the kitchen open for the command center staff and for the firefighters. We provided our corporate office, Adventist Health, and the hospitals in Chico and Oroville with frequent updates on our status; everyone was keenly interested in how soon we could reopen. Our incident commander spoke with the Office of Statewide Health Planning and Development (OSHPD), which wanted to know our status. The OSHPD representative said that before we could reopen to patients, he would need to be apprised of the hospital’s major systems and would more than likely want to do an on-sight inspection.
In the afternoon, the fire department told us that the hospital probably wouldn’t be able to reopen for another 36 hours due to shifting winds and an increase in fire threat. Our CEO gave permission to the fire department to cut down trees to create a fire break and protect hospital property. All non-essential employees were sent home. The fire had not yet crossed the Feather River, just half a mile through pine forest from the hospital, but the strong winds made it a good possibility. If it did, the fire would likely race up the Paradise side of the Feather River Canyon and be at the hospital’s door in 15 minutes. Our parking lot made us defensible, but it was possible that the fire could sweep through much of the town. The possibility made an already surreal situation that much more grim.
That night, a few of us stood in the hospital’s parking lot, looking toward Concow. Through the trees, we could plainly see the flames on the hillside across the river. Our CFO put the charts for the labor patients in his car, in case we needed to move the command center over to the clinic on short notice.
Day 4: Good news
Friday, July 11
We passed another fitful night at the hospital as the Camp Fire raged, but in the morning we awoke to learn it had not jumped the Feather River; shifting winds and firefighter efforts had contained it. The winds continued to improve throughout the day on Friday, and at around 7 p.m. the town lifted the immediate evacuation order. Our CEO called it “a miracle.”
Plans to reopen the hospital began immediately, with the goal of opening on Monday, July 14. A lot had to be done in the next two days. The HVAC systems would need to be checked, and all the filters changed because of the smoke, soot, and ash. Interior air conditioning units would have to be wiped down with degreaser. Lab equipment had to be evaluated for heat damage, since the air conditioning had been turned off, and all of that equipment would need to be recalibrated. Every piece of linen would have to be cleaned, and every surface in the hospital scrubbed.
Many of us were able to return to our own homes as the road blocks opened. I went home exhausted that night, and a little apprehensive of all the work that lay ahead of us. But it was more exciting to think that, in just a couple of days, life at the hospital would be back to normal.
Day 5: Reality sets in
Saturday, July 12
Early in the day, updates went back and forth between the hospital command center and the town, with the likelihood of all evacuation precautions lifting. Hospital directors were briefed on a plan for reopening, and a new incident management team chart was created to organize the reopening process. Our CEO made it clear that we were now in the “recovery” period of the incident. Directors were to keep in contact with our employees, and find those willing to come in and assist with the reopening. My immediate tasks included inspecting everything in the emergency department, from medications to supplies including syringes, chest tube kits, EKG stickers, and oxygen tubing.
At some point on Saturday, it became apparent that our optimism on Friday was unrealistic: there was no way we could open by Monday. Calls had been made to outside agencies to help us with hospital cleanup, but none of that additional help would actually arrive until Monday. We realized that temperature logs hadn’t been checked for a few days, meaning we couldn’t be sure that temperature-sensitive medications and equipment hadn’t been damaged during the days the air-conditioning had been turned off; it would all have to be disposed of, and restocked. The enormity of the reopening process seemed to grow by the hour.
Early Saturday afternoon, all evacuation precautions were lifted. It was great news, but it was tempered by uncertainty. I had no idea how soon we could reopen, or how soon the patients we’d evacuated could return. I just knew it wouldn’t be soon enough.
Day 6: Recovery begins
Sunday, July 13
Sunday was trash day. A large and detailed job involved tracking all of the medications in the hospital, especially those that were temperature-sensitive. If we couldn’t prove that areas of the hospital didn’t exceed 86 degrees while it was closed, any medications stored in those areas had to be returned to the pharmacy, recorded, and thrown away. We also had to find every package of lubricant, culture swab, and any other supplies that were temperature-sensitive, along with any kit (such as catheter kits) that contained betadine, an iodine solution used for cleansing skin before a procedure. The kicker was that we had bought a hospital-wide system for monitoring temperatures just a few months before, but hadn’t installed it yet. The cost of throwing away all those drugs and supplies was in the millions. Enloe, the hospital in Chico, helped us restock our pharmacy.
Based on the amount of work that had to be done, and the inspections that had to be performed, Friday, July 18 was set as the new target for reopening. I called all 30 of my emergency department staffers and told them we had some cleaning to do in the next couple of days, and made a schedule for people to help in the emergency department.
I learned that two nurses and one physician lost their homes to the fire, and that money was being raised for them.
Days 7, 8, and 9: Meeting regulations
Monday, July 14, to Wednesday, July 16
On Monday, help finally arrived to assist with the cleanup and reopening preparation. Before we could open our doors, we would have to meet an array of regulations enforced by the California Department of Public Health (CDPH) and the Office of Statewide Health Planning and Development (OSHPD). For general cleanup, hospital staff would handle the small stuff, but we contracted with professional cleaners to do all of the walls, ceilings, and carpets. These would be inspected by CDPH on Thursday. We would also check the kitchen, including the refrigerator and ice machine filters, for signs of smoke, according to CDPH regulations. Preventative maintenance had to be done on generators, which would then be tested in OSHPD’s presence; test the water supply for sprinkler heads; perform a full test of fire and smoke alarm systems that included every smoke detector, duct detector, and pull station; recertify the medical air system; and clean every duct and change every filter in the hospital’s HVAC system, which totaled 908 filters at a cost of $90,000. Those three days passed in a blur for all of us.
Two TV news channels arrived to film the recovery process as massive amounts of new supplies arrived. The kitchen passed CDPH inspection.
Day 10: Inspections
Thursday, July 17
OSHPD surveyed the hospital’s generators, fire alarm systems, medical air quality, medical gases, steam and domestic water systems, and HVAC systems. CDPH checked the pharmacy, nursing units, and other areas. All passed. We began working on the transfer of evacuated hospital patients back to Feather River, along with their medical records and equipment. Directors contacted staffers to tell them the hospital would reopen the following morning, albeit with a reduced staff; the plan was for the hospital to return to full strength over the course of a few weeks. Many of the patients evacuated on July 8 had been treated and discharged at the cooperating hospitals, and only a handful were coming back. We would begin admitting new patients on Friday and slowly build up in the coming weeks.
Day 11: Reopening
Friday, July 18
At 8:45 a.m., the first patient drove up to be seen in the emergency department—but it wasn’t open yet, because about 40 staffers and community members were attending a ceremony in the parking lot to mark the hospital’s reopening. A few emergency department staffers left to care for the patient, who complained of vomiting. Following brief remarks by our CEO and our congressman, Rep. Wally Herger, and a blessing by our director of chaplain services, the “CLOSED” sign that had covered the hospital’s sign for nine days was finally taken down. There was an enormous sense of relief as we cheered, and many of us had tears in our eyes; closing the hospital had been unthinkable, and unprecedented, but we’d been faced with conditions that forced us to do just that.
Now, at last, we were back in business. It was time to get to work.