Where There is Smoke: Wildfire Preparedness as a Health Care Provider

The threat of wildfires around the world is increasing, with fires becoming more severe and more frequent. Despite this new normal, much of the world remains unprepared to face this challenge.

“With climate change leading to warmer temperatures and drier conditions and the increasing urbanization of rural areas, the fire season is starting earlier and ending later,” the World Health Organization (WHO) site's Wildfires page reads. “Wildfire events are getting more extreme in terms of acres burned, duration and intensity, and they can disrupt transportation, communications, water supply, and power and gas services.”¹

Smoke and inhalation of fine particulate matter is enough of a danger in and of itself, with its effects including lung damage, pulmonary inflammation, flares in atopic diseases, and exacerbations of other conditions with which many people struggle such as COVID-19.²

These global threats have even led to a warning statement last month by the UN Secretary-General Antonio Guterre indicating that international cooperation on this matter is vital in the modern age, with Guterre noting that world leaders appear to be incapable of coming together to respond.³

Whether or not world leaders will yet take seriously the topic of climate and the consequent effects of wildfires on daily life, there is no question that the medical and public health communities have been thrust into the front lines of the fight against wildfires and their effects on patients across the world.

As the world struggles to prevent the far-reaching consequences, the imperative to develop efficient and robust wildfire response measures in at-risk healthcare facilities has become paramount. In an era marked by the ever-increasing threats, there is a critical role played by hospitals and health care providers in ensuring the safety and well-being of their patients, staff, and the surrounding community.

There is a growing need for protocols and procedures, especially in the case of innovative strategies hospitals are using or should begin using to safeguard lives and healthcare infrastructure in the face of escalating wildfire risks. Whether they are prepared is another story.

But what happens when a medical facility itself becomes threatened?

Today, it has become vital for medical facilities to develop comprehensive emergency response plans that cover specific procedures and protocols to follow during a wildfire event or evacuation. These plans can involve collaboration with local emergency management agencies, fire departments, and other relevant authorities.

“For patients dependent on equipment, we have to make sure that we’re prepared,” Skip Skivington, vice president of healthcare continuity and support services for Kaiser Permanente was quoted as saying. “It’s almost like a spiderweb, and you have to touch so many points to make sure that everyone is as safe as they possibly can be.”⁴

Where There is Smoke: Wildfire Preparedness as a Health Care Provider

Today and Tomorrow’s Greatest Threats

The blistering reality of climate change has brought about a new normal, where wildfires are no longer isolated incidents but recurrent and often ruinous events. A quick glance at the devastation witnessed by those living in Maui during the horrific fires of August 2023 is enough to show the incredible speed at which a series of wildfires can bring an entire community to its knees.⁵

Life-altering wildfire events such as these appear to be happening at greater rates and with greater intensity than in decades prior. The US Geological Survey reports that the increased temperatures and the rise in droughts often resulting from climate change are among the factors known to contribute greatly to the increasing intensity of wildfires.⁶

In addition to the danger fires pose in terms of burns and structural damage, the particulate matter (PM_2.5) originating from wildfires is known to be linked to premature fatalities within the general populace. Exposure can worsen issues impacting various organs and systems, including the heart, lungs, gastrointestinal tract, skin, kidneys, eyes, nose, liver, and even the brain and nervous system.²

Interestingly, cognitive impairment and loss of memory have also been linked to PM_2.5 exposure. Firefighters and emergency response professionals inherently face major risks, including injuries, burns, and smoke inhalation, especially when exposed to high concentrations of wildfire smoke.

There is a pressing need for more interdisciplinary research to comprehensively comprehend the latent and long-term health consequences of wildfire exposure, especially on vulnerable demographics such as children, pregnant people, the elderly, and individuals with chronic illnesses.

More concerning still is the effect smoke has had on historically disadvantaged communities, which can often face even worse outcomes. A study assessing the characteristics of such communities in the US which had been exposed to wildfire smoke from 2011 – 2021 showed that among the exposure increases found in this study, racial or ethnic minorities saw a 449% increase and people at lower socioeconomic status saw an increase of 346%. These statistics on social vulnerability demonstrate the urgent need for attention to climate change and measures to protect vulnerable individuals against wildfires.⁷

With these health concerns in mind, and knowing the potentially devastating effect of wildfires on disadvantaged groups, the safety of a community’s medical facilities is depended on by numerous people. So, what happens when even the security that a hospital provides itself falls under threat?

Hospitals, Care Providers, and Protecting Patients

In the midst of this shift of the global paradigm, hospitals have emerged as pivotal bastions of resilience, tasked with maintaining patient care and community support even in the most dire circumstances. This can be a daunting responsibility, and many healthcare institutions in the US and around the world have emergency strategies designed to adapt to the challenge.

To illustrate the issues which hospitals face in the event that a fire becomes a threat to their own facilities and patients, the protocols of a hospital system in the heart of California can give
unique insights on the best way to respond to the menacing possibility that the last bastion of safety in a community is threatened.

The state of California is a region that is severely affected by wildfires, thanks to the intense winds of the Sierra Nevada mountains coupled with the dry climate and infrequent rainfall. As a result, California’s hospital systems have detailed protocols in place to address the heightened threat and may be looked to as excellent examples for the rest of the country as far as disaster preparedness.

The Providence Health & Services system comprises a set of hospitals and clinics that have just such a set of methodology. These protocols were discussed with the editorial team of HCPLive through Andy Ward, the manager of emergency preparedness for 3 Providence hospitals: Providence Cedars-Sinai Tarzana Medical Center, Providence Holy Cross Medical Center, and Providence Saint Joseph Medical Center.

“(Los Angeles) County has what's called a Disaster Resource Center program, where there are hospitals throughout the county that are designated as disaster resource centers, and they're kind of the hubs and spokes for something like wildfires or COVID,” Ward explained. “And Saint Joseph is the Disaster Resource Center for our half of the valley.”

This preparedness system, Ward explained, resulted from the federal response to the events of September 11th. The aftermath of 9/11 and Hurricane Katrina in 2005 led to the federal government identifying critical regions that could benefit from greater preparedness and better funding for disasters, with one being Los Angeles.

“So, LA County is actually doing something kind of unique, where they are giving the money that they received from the federal government through the state directly to these DRCs,” Ward said. “And then it goes to what they call umbrella hospitals, which are basically all the other hospitals in the County. Then those hospitals are assigned to a DRC based on their geographic area.”

An Example of Protocols for Wildfire Threats

Ward explained that the staff at Providence follow what is called the Hospital Incident Command System (HICS). During an emergency such as a wildfire threat to the facility, the following events occur under their protocols:

• Typically the nursing supervisor in charge on a day to day basis will serve as the “initial incident commander,” escalating the situation depending upon their information and the time of day.
• If the threat occurs in the middle of the day and many staff are present, they can get help quickly. If it happens at 3 AM on a holiday, for example, they will likely have to react faster to call staff in.
• The initial incident commander calls the “AOC,” or administrator on call, who is typically in senior leadership such as the CEO or Director of Nursing, and then they would start calling others as the command center is activated.
• If only smoke is impacting the facility, then that command center is going to be a little more “facilities-heavy.” If the fire is going to impact patients physically, then it would be a mix.
• At a minimum, the hospital would have an incident commander, documenter of all the information, and a safety officer. They may also use a liaison, a public information officer, and a medical technical specialist.
• Then the facility would start to break out into operations, which would cover the patient care areas, logistics, planning, finance. Ward himself would be there to help the command center function.
• The staff would do what's called a Code Triage, a notification to the hospital to the staff and patients about the threat.
• The staff uses a disaster status report and they bring this to the command center. They inform the center whether they are impacted, if they need any resources, and if any areas face immediate risk. From then on, the decisions to evacuate may occur if needed.

Ward noted that the key in such events is situational awareness, getting all the necessary information circulated, and getting actionable intelligence from fire departments and from the community.

“Embers can travel kind of far, so from the patient safety perspective you have got to look at it a couple different ways: One, you have the patients that are in-house, so are you protecting them?” he explained. “Are you making sure they're safe? Are you making sure their families know what's going on? Making sure their families are aware and for patients that might come for outpatient procedures, making sure they're safe and making sure they have good information.”

If it comes to evacuation, Ward noted that this can be much more difficult, because staff must begin looking at where to evacuate the entire hospital, and evacuating patients is always the last thing hospitals want to do unless there is an extreme safety risk inside the hospital.

“If we take ICU patients or NICU patients and move them outside into a smoky environment and put them in an ambulance that probably doesn't have the units in the back, they might have a very bad outcome,” he said. “So, we have to look at that. Typically in an evacuation, we prioritize those who can move on their own, and we actually tend to move the sickest patients last. If that seems a little counterintuitive, it's because they're going to require the most resources, and they're the most vulnerable.”

Lizette Cuvin, MSN, RN, a nurse manager at Providence Holy Cross Medical Center’s Emergency Department, also spoke with HCPLive on her work with disaster management to improve the evacuation plan at Holy Cross.

Cuvin noted that medical facilities across the country may wish to pay close attention to their strategies, as the rise of virtual communication in the wake of COVID-19 may have unforeseen consequences when it comes to preparedness.

“We're required to receive fire safety training once every 4 years,” she explained. “And honestly ever since COVID, it's been very difficult because things are virtual. So it's not the same where it used to be very hands on. They would give you fire drills and show you how to put out a fire, know the acronyms like pass and the SWEEP and everything like that. It's different nowadays.”

Cuvin added that COVID-19 led to an increase in staff turnover among hospitals across the country, and explained that this turnover was also observed in the disaster department.

“Now that I'm here and now that we have a more solid disaster team, I feel like we're doing a great job building that relationship and rolling out that education that all our caregivers need in order to serve all the patients,” Cuvin said.

The statements of these leaders from the Providence hospital system in California highlight the necessity of education, information sharing, and a system in place for any eventuality. Many facilities around the country, however, may not yet recognize their own risks.

In a world of increasingly frequent and devastating wildfires, many of which heavily impact places such as California as well as other regions, the necessity of well-planned evacuation and fire safety procedures in hospitals cannot be overstated. The institutions are not just places of healing; they are lifelines for communities in times of crisis.

While world leaders work out a response to climate crises across the globe, the value of well-organized medical facilities in the US and around the world becomes more apparent. As the medical community looks to the future, it is vital to continue to prioritize and invest in the resilience of healthcare facilities so that they may stand as beacons of safety for communities in peril, even in the face of nature's rising challenges.

References

1. ^{Wildfires. World Health Organization. Date accessed: October 3, 2023. https://www.who.int/health-topics/wildfires#tab=tab_1.}
2. ^{Suran M. Raging Wildfires Are Exposing More People to Smoky Air—Here’s What That Means for Health. JAMA. Published online September 21, 2023. doi:10.1001/jama.2023.13606.}
3. ^{Lederer E. The UN chief summons world leaders to action. But, he says, they seem ‘incapable of coming together.’ APNews. September 19, 2023. Date accessed: October 3, 2023. https://apnews.com/article/world-leaders-un-war-climate-change-inequality-8fd633d3f7f1b2d8934950439152cfec.}
4. ^{Fink C. Hospitals must prepare for deadlier, more destructive wildfires. Health Facilities Management Magazine. May 12, 2022. Date accessed: October 3, 2023. https://www.hfmmagazine.com/articles/4440-hospitals-must-prepare-for-deadlier-more-destructive-wildfires.}
5. ^{Harris E. US Government Declares Public Health Emergency in Hawaiʻi. JAMA. 2023;330(10):905. doi:10.1001/jama.2023.15445.}
6. ^{Wildfire and Climate Change. US Geological Survey. Date accessed: October 3, 2023. https://www.usgs.gov/science-explorer/climate/wildfire.}
7. ^{Jason Vargo, Brooke Lappe, Maria C. Mirabelli, Kathryn C. Conlon, “Social Vulnerability in US Communities Affected by Wildfire Smoke, 2011 to 2021”, American Journal of Public Health 113, no. 7 (July 1, 2023): pp. 759-767. https://doi.org/10.2105/AJPH.2023.307286.}