Health care has transformed over the past quarter century. Great strides in technology, an aging population, the Affordable Care Act, and many other factors have changed the way care is delivered in America. Many of these factors also have affected fire safety in health care facilities.

According to NFPA, in 2010 U.S. fire departments responded to 1,200 fires in hospitals and 2,510 in nursing homes.¹ While the figure for nursing homes has remained relatively flat (2,650 fires in 1989), the number for hospitals has dropped significantly from 3,210 in 1989. This improvement in hospital fires is due to several factors, including a reduction in flammable materials, better emergency training for staff, and federal enforcement of the NFPA Life Safety Code since 1970.

This article will discuss changes in hospitals, nursing homes, and assisted living facilities, with particular emphasis on changes that have affected fire safety.

First, however, here is a brief overview of major trends affecting health care:

An aging population. Americans are growing older. In 2008, it was estimated that 43.1 million Americans were over age 65.² Experts estimate that 72.1 million will fall into that category in 2030. This has had a profound impact on health care, and on fire safety in hospitals and long-term care facilities.

Naturally, older individuals tend to require more health care services, so as the country ages, the need for health care increases. In 2008, expenditures on health care totaled about $2.3 trillion, according to the National Center for Health Statistics.³ By 2022, that number will probably exceed $5 trillion.

The impact to fire safety of more patients, and in particular aging patients, is discussed in more detail in the sections about hospitals and long-term care facilities later in this article.

Technology. Health care technology has made major advances in the past quarter century. Among the most important advances have been technology related to use of the human genome, an increase in information technology, and effective treatments for heart disease.

However, from a fire safety perspective, the most important developments have been treatment options that require large pieces of equipment, such as linear accelerators and robotic surgical tools. This equipment requires space, and is sometimes located in areas of hospitals that are already tight, especially when they are moved into existing spaces that were not designed specifically for that equipment.

Regulations. Health care is the second-most regulated industry in the country, following only the power industry. Countless laws affect all health care operations, ranging from local municipal codes to major federal programs such as the Centers for Medicare & Medicaid Services.

Health care facilities often are inspected by multiple authorities having jurisdiction (AHJs), which makes compliance challenging. For example, many state fire marshals have adopted NFPA's Life Safety Code as the primary code in the state, but local municipalities may have other requirements that need to be met, or they may have adopted a different edition of the Life Safety Code.

Undoubtedly, the most important regulatory change in health care over the past quarter century was the 2010 Affordable Care Act. While the impact of this act is still a long way from playing out, it has already forced health care facilities to tighten budgets and prepare for an influx of new patients.

New hazards. New hazards also have emerged in the past 25 years. For example, to address the serious hazard of infection control, alcohol-based disinfectants are located throughout health care facilities, including exit corridors. To address the security of infants and young children in hospitals, egress doors from nursery and pediatric units have to be locked. Similarly, to address the hazard of elopement (to run away) in long-term care facilities, egress doors must be locked.

The sections that follow provide specifics about how changes in health care have affected fire safety issues.

CHANGES TO HOSPITALS AND RELATED FIRE-SAFETY ISSUES

Hospitals have become safer over the past quarter century. As noted above, the number of fires in hospitals has dropped substantially since 1989, due largely to reductions in flammable materials and improved staff training. Another factor is that smoking is no longer permitted except in specific circumstances by the Joint Commission.⁴

The advantages of improved emergency preparedness training were evident during Hurricane Sandy in 2012, when dozens of hospitals on the East Coast were safely evacuated or cared for their patients using emergency power. This event proved that well prepared hospital staff can defend-in-place when they need to, and can evacuate without loss of life when necessary.

When fires do occur in hospitals today, improved fire alarm systems and sprinklers help contain damage. And factors such as universal room design and reduced crowding help when evacuation is necessary.

Some factors, however, have exacerbated fire concerns over the past 25 years. For example, a growing number of bariatric patients pose evacuation challenges, and budget concerns sometimes cause leaders to question fire safety improvements.

These issues and others are described briefly in the following sections.

Increased emphasis on emergency management. The Joint Commission (the primary accreditation agency for health care organizations in the United States) requires hospitals to have a thorough emergency management program; recent severe weather problems, such as hurricanes on the East Coast and tornadoes in the Midwest, have raised the issue to an even higher priority. Fires and explosions are among the emergencies the program must address, according to the Joint Commission.

Improved fire alarm systems. Hospital fire alarm systems and policies have improved over the past quarter century. Among the improvements is the expanded use of addressable fire alarm systems, which provide firefighters with more information and help them pinpoint the source of a fire. Another advance is the increased amount of communication between fire alarms and other hospital systems. For example, when a fire alarm is activated, the system will switch the elevator system to a fire setting, enable audible exit notification systems, and manage HVAC systems for fire control.

Additional requirements for automatic extinguishing equipment. Requirements for sprinklers have grown over the years, and the result has been better suppression of hospital fires. According to data from the National Fire Protection Association, between 1980 and 1984, automatic extinguishing equipment was present in 47% of hospital fires; between 2007 and 2011, that figure had risen to 78%.⁵ In hospital fires in which the sprinklers operated effectively, the fire was contained to the room of origin 92% of the time.

Staff training expectations. Hospital staff is much better trained today in emergency preparedness. For example, staff are now expected to be ready to "defend-in-place," as mentioned above. This includes understanding the RACE protocol- Relocate, Alarm, Contain, Extinguish -which instructs staff dealing with a fire to move patients to safe areas (or keep them in their rooms, if preferable), alert emergency personnel, contain the smoke and flames to the point of origin as much as possible, and deploy a fire extinguisher, if possible.

Reduction of flammable materials. Over the past several decades, hospitals have reduced the volume of several categories of flammable materials they store and use. For example, traditional anesthetics, such as ether, are flammable when enough oxygen is present, but they have been virtually eliminated from operating rooms in the past 40 years. The concentration of oxygen tanks, a contributor to the potential fire hazard, has dropped because hospital building codes today require private rooms, which means fewer patients-and consequently fewer oxygen tanks-in any given space.⁶ Finally, the increased use of digital radiology has reduced the volume of flammable X-ray film and chemicals that hospitals store. Digital radiology, which transfers images directly to computer screens rather than using film, has slowly overtaken traditional film-based radiology since the early 1990s.

Improved operating room safety. As previously noted, flammable anesthetics are no longer used in operating rooms, reducing the fire hazard. This has led to other changes in operating room design and construction. For example, the 1999 edition of NFPA 99 required relative humidity in operating rooms to be 35% to prevent static discharge; now, 20% is considered satisfactory. Similarly, conductive flooring, which reduces static discharge, is no longer required.

Operating rooms no longer are built with second-story observation galleries, since video has replaced that need. Furthermore, smoke exhaust systems have been eliminated in many operating rooms because it was found they were unnecessary. Both of these changes have reduced the complexity of operating room design, and consequently improved fire safety.

Increased requirements for interim life safety measures (ILSM). Interim life safety measures (ILSM) are health and safety measures designed to protect the safety of patients, visitors, and staff during construction, when regular life safety measures may be inoperable. The Joint Commission has established standards for ILSM.⁸ For example, if a renovation project results in the fire alarm or sprinkler system being disabled for more than a limited number of hours in a 24-hour period, the local fire department must be notified and the hospital must establish a fire watch.

Improved communication technology. Today's hospitals have vastly improved communication technologies compared to 1990. For example, many hospitals employ smartphone-based systems that allow an emergency message to be quickly disseminated to all staff. In the case of a fire, such a system could be used to initiate emergency plans and locate staff.

Defend-in-place strategies becoming more prevalent. The practice of "defending-in-place" during a fire, which means patients are not evacuated but measures are taken to keep them safe, has risen over the past two decades. Evacuation is simply not feasible for many patients, especially those connected to life support. So these patients may be moved to "protected areas" on the same floor that is designed to limit the exposure of smoke or fire to the patients in the area.

Reduced crowding in hospitals. Intuitively, a less crowded space is a safer space. Fewer people mean fewer oxygen tanks-which are a potential contributor to the fire hazard-and fewer people in need of rescue. Fewer people also theoretically means a less tumultuous evacuation. The rate of days of in-hospital care per 1,000 Medicare enrollees fell from 3,890 per year in 1980 to 1,874 in 2010.⁹ There are several reasons for this. A growing dependence on outpatient treatment-often made possible by improved medical technology means many people who would have been admitted in 1990 today are treated and released the same day. A closer watch on cost during that period has contributed to a reduction in length of stay, as has the general understanding that many patients would rather recuperate at home than in a hospital.

Another factor that has reduced hospital crowding is the growth of alternative treatment centers. For example, specialty hospitals that focus on one type of care-sports medicine, joint replacement, etc.- keep some patients out of the general hospital population. And since those hospitals specialize in treating a limited number of conditions, their speed of care may be faster. Walk-in clinics in pharmacies and grocery stores are an alternative to hospital treatment. While these clinics do not replace emergency departments, they presumably see some patients who otherwise would have visited the local hospital.

However, one important factor that may affect the downward trend in hospital utilization is the 2010 Affordable Care Act. About 9 million Americans who previously were uninsured now have insurance, according to a June 2014 Gallup poll, and that probably will lead to more hospital patients.

AREAS OF FIRE SAFETY CONCERNS IN HOSPITALS

Despite all the advances in fire safety in hospitals, some areas of concern still remain.

Increased prevalence of infection prevention isolation areas. The increased understanding of infection control in hospitals over the past several decades has increased the fire hazard and potentially made it more difficult for fire rescue personnel to access areas of the hospital. Alcohol-based hand rubs (ABHRs) have been introduced into facilities for infection control purposes. These ABHRs are typically flammable liquids and can contribute to a fire and its spread. Limits on the use of ABHRs have been established to minimize this hazard, which is based on fire modeling.¹⁰ In addition, infection prevention areas often have anterooms that divide them from the main rooms, making it harder for rescue personnel to maneuver. The fact that a patient is being kept in an infection isolation room implies that he or she should not be exposed to outside air, either for the patient's safety or the safety of others, further complicating a rescue.

Rapid changes in medical technology. While improved medical technology has played a major role in reducing the number of in-patients, which is a positive fire-safety factor, in some cases it has complicated hospital floor plans. For example, when an existing hospital installs a linear accelerator-a device that delivers high-energy x-rays to tumors-it may need to squeeze the large piece of equipment into a tight space, creating a potentially difficult fire-fighting situation.

Financial concerns. The American Hospital Association estimates that Medicare and Medicaid paid hospitals only 86 cents for every $1 in care they provided to Medicare and Medicaid patients. Since Medicare and Medicaid account for 58% of hospital reimbursements, it's easy to see why many hospitals are in a tight financial situation.¹¹ One consequence of under compensation as well as other spending-related issues such as charity care and inflation-is that hospital leaders keep a tight watch on all expenditures, including those for fire safety issues.

Increasing bariatric concerns. The incidence of overweight and obese people is growing in the United States. According to the Centers for Disease Control and Prevention, 34.9% of adults in America suffer from obesity. This affects fire safety, because large individuals may be more difficult to evacuate. Ambulance companies have invested in bariatric cots, for example, but these are expensive and do not carry the largest individuals.

Health information portability and Accountability Act (HIPAA). The Health Information Portability and Accountability Act (HIPAA), which was enacted in 1996, has compelled hospitals to remove patient identification information from many places. This raises a potential problem of being unable to determine if everyone was evacuated during an emergency.

CHANGES TO LONG-TERM CARE FACILITIES AND RELATED FIRE SAFETY ISSUES

Long-term care facilities have become significantly safer over the past 25 years. Nursing home deaths caused by multiple-death fires dropped from an average of 4.3 per year in the 1970s and 1980s to 1.7 deaths per year in the last 20 years. Deaths by fire in assisted living facilities (ALFs) also have dropped dramatically in recent decades, including a 70% drop over the past 10 years.^12,13

Although an assisted living facility is technically not a health care occupancy, some of the residents are incapable of self preservation and the requirements for these facilities in both the NFPA Life Safety Code and the International Building Code- 2015 edition (I-1& R-4 Occupancies, Condition 2) are similar to health care occupancies. That is the basis for including ALFs in this article.

In 1970, the Centers for Medicare & Medicaid Services (CMS) adopted the Life Safety Code-1967 edition for all nursing homes. CMS currently uses the 2000 edition and is in the process of adopting the 2012 edition. Fire/ life safety for assisted living facilities is regulated by the states and state requirements differ greatly.

The key factor in the reductions in long-term care facilities has been the increase in mandatory automatic sprinkler installations and the better coordination of requirements.

Increase in the use of sprinklers. The Life Safety Code required that all new nursing homes be built with sprinklers starting in 1991. In 2008, the federal government, with industry support, mandated that all existing nursing homes be provided with automatic sprinkler protection throughout by 2013. Consequently, every nursing home today is protected with automatic sprinklers throughout. Every nursing home fire that resulted in multiple deaths since 1972 was in a facility without sprinklers. Having all nursing homes provided with automatic sprinklers should eliminate multiple death fires.

Better coordination of requirements. Health care organizations have long been involved on the committees that develop the Life Safety Codes and other NFPA standards. That involvement has ensured that the codes address the key issues and are practical for the industry. The International Building Code (IBC), which also regulates health care facilities, historically has not had the same level of health care organization involvement, but that changed during the development of the IBC-2015 edition. During the planning of the 2015 edition, the International Code Council, developer of the IBC, established temporary committees for hospitals, nursing homes, and assisted living facilities that included representatives from those industries. This was the first time that a significant effort was made to coordinate the requirements for health care and assisted living facilities in both primary national codes.

AREAS OF FIRE SAFETY CONCERN IN LONG-TERM CARE FACILITIES

Fire safety concerns in long-term care facilities vary somewhat from those in hospitals. Several changes and trends have increased the challenge of fire safety in these facilities, including a growing number of patients with dementia, a trend towards a more residential feel in long-term care facilities, and an increase in bariatric patients.

Growing acuity of residents. Perhaps the largest fire safety concern in long-term care facilities is that a majority of residents have impaired mental abilities. Statistics show that at least 61% of residents of nursing homes suffer from Alzheimer's or another form of dementia, as do 42% of residents of assisted living facilities.¹⁴ This trend will likely continue as the number of senior citizens in the United States grows; indeed, the largest area for new construction is new memory care units in assisted living facilities.

These impairments mean that most residents may be unable to evacuate without assistance during a fire. This increases the challenge during a fire for staff and rescue personnel, and increases the requirement for "defend-in-place" strategies that involve moving patients to safe areas in the building (horizontal evacuation) rather than evacuating to the outside.

Ironically, patients with dementia also are at risk of walking off from the facility, which is known as elopement. To decrease the risk of elopement, codes allow egress doors to be locked in these facilities, as long as staff is present. This practice is at odds with the theory behind allowing immediate egress in a fire emergency.

Dementia poses another risk regarding fire safety: Some individuals with dementia engage in risky activities, such as attempting to light a cigarette while using oxygen or attempting to go down stairways in their wheelchairs.

Move towards residential setting. Long-term care facilities are a resident's "home." To respond to this fact, the facilities are becoming more residential in nature. In private nursing homes, new small household units typically have 12 to 16 beds and renovated facilities have up to 22 beds, although the code allows up to 30 beds.¹⁵ This trend makes living in such a facility more pleasant, but presents some challenges to fire safety. For example, small household units now include kitchens open to the corridors in their main living areas.

Residents, who are capable, are encouraged to assist staff with meals. Kitchens are obviously a potential fire hazard, so code requirements have been implemented to reduce the risk. For example, a staff person has a key to turn off all heat-producing equipment when staff is not present in the kitchen. Also, deep fryers are not allowed.

Another change resulting from the move towards a more comfortable residential setting is that residents are allowed to hang more personal combustible items on their walls, including paper drawings from family members, drapes from their homes, and decorations. The increased use of sprinklers has facilitated this change, as previously these items were restricted. All these changes are designed to improve the quality of life of the residents.^16,17

Increasing number of bariatric patients. The number of overweight or obese individuals in nursing homes and assisted living facilities is growing. These individuals are more difficult to evacuate in a fire and larger-size wheelchairs, gurneys, and other mobility equipment are often needed.

Fixed seating in hallways. A clear egress path is an important fire safety issue. However, nursing home residents sometimes are unable to walk very far, so having a place in a hallway to stop and rest is essential. Consequently, the Life Safety Code-2012 edition and the IBC-2015 edition allow for fixed seating in corridors, where the width of the corridor is at least 8 ft., which was previously prohibited.^15,16

Chad Beebe is with the American Society for Healthcare Engineering; Eric Rosenbaum is with JENSEN HUGHES; Thomas Jaeger is with Jaeger & Associates LLC.

References:

1. Ahrens, M. 2012. Fires in Health Care Facilities National Fire Protection Association, Fire Analysis and Research Division. Viewed online Oct. 13, 2014: http://www.nfpa.org/~/media/FilesResearch/NFPA%20reports/Occupancies oshealth carefacilities.pdf.
2. 2. U.S. Census Bureau, Current Population Estimates, May 2014. Viewed online October 13, 2014: http://www.census.gov/prod/2014pubs/p25-1140.pdf.
3. National Center for Health Statistics. Health, United States, 2010: With Special Feature on Death and Dying. Hyattsville, MD. 2011. Viewed online Oct. 13, 2014: http://www.cdc.gov/nchs/data/hus/hus10.pdf.
4. The Joint Commission Standard EC.02.01.03. The Joint Commission, Oakbrook Terrace, IL.
5. Ahrens, M. 2012. Fires in Health Care Facilities. National Fire Protection Association, Fire Analysis and Research Division. Viewed online October 13, 2014: http://www.nfpa.org/~/media/Files/Research/NFPAreports/Occupancies/
   oshealthcarefacilities.pdf.
6. Facility Guidelines Institute, Guidelines for Design and Construction of Health care Facilities. 2.2-2.2.2.1 Capacity.
7. NFPA 99: Health Care Facilities Code, 2012. National Fire Protection Association. Quincy, MA.
8. The Joint Commission, Standard LS.01.02.01. The Joint Commission, Oakbrook Terrace, IL.
9. Centers for Medicaid & Medicare Services, 2010, Table 5: Discharges, Total Days of Care, Total Charges, and Program Payments for Medicare Beneficiaries Discharged from Short- Stay Hospitals, by Type of Entitlement: Calendar Years 1972-201. Viewed online on Oct. 24, 2014: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareMedicaidStatSupp/Medicareand-Medicaid-Statistical-Supplement-Items/CMS1255218.html.
10. Jaeger, T., Leaver, C., and Glenn, R., "Alcohol Based Hand Rub Solution Fire Modeling Analysis Report." 8-22-2003.
11. American Hospital Association. (http://www.aha.org/content/14/2012-medicare-med-underpay.pdf).
12. American Health Care Association, Nursing Home Multiple Death Fires 1974-2013, Jaeger & Associates LLC, revised July 2014.
13. National Center for Assisted Living, Assisted Living Multiple Death Fires 1973-2012, Jaeger & Associates LLC, Revised July 2014.
14. Long Term Care Services in the United States: 2013 Overview, National Center for Health Statistics.
15. NFPA 101: Life Safety Code, 2012. National Fire Protection Association. Quincy, MA.
16. National Fire Protection Association and NFPA Fire Protection Research Foundation. National Trends in Delivery of Health and Long-Term Care: Implications for Safety Codes and Standards, Report of a National Summit, March 28 & 29, 2012, Baltimore, Md.
17. National Fire Protection Association and NFPA Fire Protection Research Foundation. National Trends in Delivery of Health and Long-Term Care: Implications for Safety Codes and Standards, Report of a National Summit, June 20 & 21, 2010, Baltimore, Md.