A11100 Tflbt.70

rr

NBS

PUBLICATIONS

NBSIR 79-1906 A1110S 042772

The Evacuation of Non-Ambulatory

Patients from Hospital and Nursing Home

Fires: A Framework for A Model

John Archea*

(Stephen T. Margulis, Editor)

Center for Building Technology

National Engineering Laboratory

National Bureau of Standards

Washington, D.C. 20234

November 1979

Prepared for Program for Design Concepts

Center for Fire Research

National Engineering Laboratory

Washington, D.C. 20234

Sponsored by

Public Health Service

U.S. Department of Health, Education and Welfare

“Currently at the College of Architecture

Georgia Institute of Technology

Atlanta, Georgia 30332

100

,U56

79-1906

1979

C.2
*
NBSIR 79-1906

• • < THE EVACUATION OF NON-AMBULATORY

PATIENTS FROM HOSPITAL AND NURSING HOME

FIRES: A FRAMEWORK FOR A MODEL

Bin-eau tf’SnfiWSCflR FFB 8 1980

&Q U£>

C/SL

JCiT

c - 3-

John Archea*

(Stephen T. Margulis, Editor)

Center for Building Technology

National Engineering Laboratory

National Bureau of Standards

Washington, D.C. 20234

November 1979

Prepared for Program for Design Concepts

Center for Fire Research

National Engineering Laboratory

Washington, D.C. 20234

Sponsored by

Public Health Service

U S. Department of Health, Education and Welfare

‘Currently at the College of Architecture

Georgia Institute of Technology

Atlanta, Georgia 30332

U S. DEPARTMENT OF COMMERCE

~

Luther H. Hodges, Jr., Under Secretary

Jordan J. Baruch. Assistant Secretary for Science and Technology

NATIONAL BUREAU OF STANDARDS. Ernest Ambler. Director
o 7 i\ VCl

j

• IR

.

.

••

» •

... ,;i .
TABLE OF CONTENTS

Page

ACKNOWLEDGEMENTS vii

viii

ABSTRACT

Introduction 1

Nature of the Report 1 Organization of the Report 2

1. Defining the Problem 3

1.1 The Hydraulic Model 3

1.2 Non-ambulatory Patients 5 1.3 Removal From the Threatened Zone 7 1.4 Supply of Preparation Manpower 9

1.5 Resupply of Manpower 11

1.6 Manpower Organization 13

2. The Evacuation Process 17

2.1 Manpower Supply Phase 18

2.2 Patient Preparation Phase 18

2.3 Patient Removal Phase 20

2.4 Rest and Recovery Phase 24

2.5 Manpower Resupply Phase 24

3. Evacuation as a System • t 28

3.1 Relationships Among the Five Phases of the System 29

3.1.1 Fire Development 29

3.1.2 Weighted Mobility Status 29

3.1.3 Spatial Distribution 29

3.1.4 Task Proficiency 30

3.1.5 Manpower Organization 30

3.2 System Performance Measures 30

4. Guidelines for the Design and Assessment of Evacuation

Systems 32

4.1 Design Conditions 32

4.1.1 Critical Initial Conditions 32

4.1.2 Ideal Performance Conditions 34

iii
Page

5. Recommended Research on the Evacuation Process: An Agenda 38

5.1 Initial Condition Measures 38

5.1.1 Mapping of Staff and Patient Routines Throughout

the Daily Cycle 38

5.1.2 Modeling of the Spatial Organization of Health

Care Facilities 39

5.1.3 Studies of the Accessibility of Egress Routes 39

5.1.4 Recording the Points of Origins of Health Care

Facility Fires 40

5.1.5 Field Observations of Emergency Training

Procedures and Drills 40

5.1.6 Determination of Critical Design Conditions 40

5.2 Performance Measures 41

5.2.1 Determination of Manpower Supply and Resupply

Rates 41

5.2.2 Studies of Alternative Preparation Procedures

Under Stress 42

5.2.3 Studies of the Movement Capabilities of the

Elderly and Handicapped 42

5.2.4 Studies of Alternative Removal Procedures

Under Stress 42

5.2.5 Studies of the Use of Information in High-risk

Decisionmaking and in Route Selection Under

Stress 43

5.2.6 Studies of the Effects of Overmanning on the

Evacuation Process 44

5.2.7 Simulations of Total Evacuation System

Effectiveness 44

5.2.8 Calculation of Optimal Evacuation and Training

Procedures 44

5.3 Intermediate Protection and Evacuation Trade-offs 45

5.3.1 Studies of Occupants' Confidence in the Fire

Safety of an Intermediate Protection System

During a Fire 45

5.3.2 The Impact on Closing and Closed Doors on Initial Response Time 46

5.3.3 Simulations of Protection Versus Evacuation

Options 46

6. Summary and Conclusions 48

References 51

iv
Appendix 1. Introduction and Key to the Schematic Diagrams

of the Evacuation Process
1

2

3

4

5

6

7

8

9

10

11

12

LIST OF FIGURES

Page

The Hydraulic Model 4

Non-ambulatory Patients 6

Removal for the Threatened Zone 8

Supply of Preparation Manpower 10

Resupply of Manpower 12

Manpower Organization 14

Summary of Major Factors 16

Manpower Supply Phase: Examples of Factors 19

Patient Preparation Phase: Examples of Factors 21

Patient Removal Phase: Examples of Factors 22

Rest and Recovery Phase: Examples of Factors 25

Manpower Resupply Phase: Examples of Factors 27

vi
ACKNOWLEDGEMENTS

The report is a product of the HEW/NBS Fire and Life Safety Program,

sponsored by the Public Health Service of the Department of Health,

Education and Welfare (HEW). This program is a joint effort of HEW and

NBS (National Bureau of Standards) to develop rational, technically

sound solutions to fire problems in health care facilities. In addition to the types of work described in this report, the joint program

has produced products in the areas of: decision analysis, fire and

smoke detection, smoke movement and control, automatic extinguishment,

and behaviors of institutionalized and other populations in fire

situations.

The author extends his appreciation to Dr. Stephen T. Margulis,

Dr. Fred I. Stahl and Dr. Robert Wehrli for their generous contributions

of substantive and editorial suggestions on an earlier draft of this

manuscript. A very special note of thanks is extended to Candace Roat

for her sustained contributions and for her many helpful comments and

suggestions on the earlier draft. The author's draft was edited into

the present report by Dr. Margulis. The editor wishes to thank the

author and his colleagues in the Center for Building Technology for

their helpful comments. He also wishes to thank Miss Tracey Kistler

for the typing of this report.

vii
ABSTRACT

This report is directed toward the problem of evacuating dependent,

non-ambul atory persons from fires in nursing homes and other health

care facilities. It deals only with those behavioral and building factors that bear on the activities that follow directly from a decision to

evacuate patients from a fire zone in a nursing home or similar facility.

The examination is based on the rejection of the model which is the basis

for current life safety regulations because it assumes independent occupant mobility. This assumption does not apply to dependent, non-ambulatory persons. The major objective of the report is to identify those

factors that must be considered in order to determine the ideal perfor- mance of a hospital or nursing home evacuation system for non-ambulatory

patients when all components or persons in that system act as they are designed or trained to act. These factors are presented as part of an analysis of evacuation as a five phase process: manpower supply phase,

patient preparation phase, patient removal phase, rest and recovery

phase, and manpower resupply phase. Research findings are reviewed and

a research agenda is proposed.

Key words: Building codes; building evaluation; elderly; fire safety;

handicapped occupants; health care facilities; nursing

homes; user needs.
INTRODUCTION

Current fire safety regulations which affect the design of egress or protection systems in buildings are generally based on the assumption

that the building occupants are able-bodied, ambulatory, and reasonable

individuals. These regulations do not consider the predicament of

building occupants who are not able-bodied, who are non-ambulatory,

and who may be the victims of cognitive deficits, such as bed-ridden

patients in hospitals or nursing homes, or the handicapped. That is,

current fire regulations have given virtually no consideration to building occupants who cannot evacuate or protect themselves during a fire

emergency and who must have the assistance of other persons before they

can realize the benefits of most evacuation or fire protection systems

(Caravaty and Haviland, 1967; Lefer, 1976). This report addresses the

problem of evacuating highly dependent or non-ambulatory patients from

fires in nursing homes and other health care facilities.

A growing body of research and analyses indicates (1) that current regulations underestimate the number and/or width of exit routes that would

be necessary to complete a total evacuation of a densely occupied building in the required time (Pauls, 1975; Stahl and Archea, 1977); and

(2) that current regulations are based on assumptions about human behavior during fire emergencies that are inadequate (Bickman, 1977; Bryan,

1976; Canter and Matthews, 1976; Lefer, 1976; Lerup, 1975; Wood, 1972).

Thus, new behavioral evidence may force a reconsideration of regulations

concerning evacuation route requirements and may require regulations to

take into account the impact of building occupants' behavior on the

effectiveness of fire protection systems during fire emergencies. This

report addresses both design and behavioral factors, specifically those

design and behavioral factors that can affect the activities that follow

from a decision to evacuate patients from a fire zone in a nursing home

or health care facility. Without an understanding of human behavior in

fire emergencies, egress-related physical design and emergency planning

(drills, training, educational programs) may not be effective in assuring the evacuation of all occupants safely during a fire emergency.

Nature of the Report

The report discusses building, patient and staff factors that influence

the evacuation of non-ambulatory and dependent patients of nursing homes

and health care facilities following the decision to evacuate . It does

not consider activities that precede the decision to evacuate, the

process by which that decision is made, nor the manner in which the

decision is communicated to others. Activities other than evacuation

itself, such as fire fighting or sending a fire alarm, are considered

only as they relate to the evacuation process itself.

The major objective of this report is to identify those factors which

must be considered to determine the ideal performance of a hospital or nursing home evacuation system for non- ambulatory patients when all

components or factors in that system perform as they are designed or trained to perform. This report is best characterized as a

1
comprehensive, but conjectural, problem statement that is constrained

by the results of relevant research. It is not presently an operational

guide for the conduct of fire emergency evacuations. Although the

report is, to a large degree, conjectural, the text tends to avoid

conditional and qualified statements in favor of declarative assertions.

When relevant research is being cited, it is referenced.

Organization of the Report

Chapter 1 presents a step-by-step derivation of the major factors

involved in evacuating non-ambulatory patients during hospital or nursing home fires. The chapter is theoretical, conjectural; however

it is consistent with current research reviewed in Chapter 5. Each

section in Chapter 1 has a corresponding schematic diagram to illustrate

the factors and their interrelations that are discussed. The major

factors are cast as five sequential phases of an evacuation process

in Chapter 2. The major patient, staff and building factors that can influence the activities of each phase are introduced in Chapter 2.

Examples of these factors are also presented. Four parameters, necessary for integrating the five phases into a working model of an evacuation system for non- ambulatory patients, are introduced and discussed

in Chapter 3. Although available data are insufficient to support the

development of a definitive model of the evacuation process, Chapter 3

presents factors that would have to be considered in developing such

a model. Chapter 4 considers the design and assessment of evacuation

systems. The chapter is predicated on the assumption that any analysis

of the evacuation process, ultimately, is a matter of measuring initial

conditions and system performance. Fourteen assumptions are introduced,

representing approximations of initial conditions and performance

measures, as guidelines for the design and assessment of evacuation

systems. Because there is limited research on the movement of non- ambulatory patients in nursing homes and health care facilities and

because this information is critical to the development of a definitive

model of patient evacuation, a research agenda in proposed in Chapter 5.

This chapter also reviews the available research on behavioral aspects

of fire evacuations from buildings. The final chapter, Chapter 6,

summarizes the report.

2
1 DEFINING THE PROBLEM

This chapter presents the special problems of non-ambulatory patients

during a fire emergency in the building they occupy. The chapter

considers the problems introduced by the non-ambulatory patient's

need for help from others and the problems faced by those who attempt

to provide the needed assistance during the emergency. These problems

show the limitations of the currently accepted model of the uninterrupted flow of able-bodied evacuees through fire-protected means of

egress. The research which support the ideas developed in this chapter

appears in Chapter 5.

1.1 THE HYDRAULIC MODEL

Most current building egress regulations are based on what might be

called a "hydraulic model." This model makes three important assumptions: (1) building occupants are alert, able-bodied and ambulatory;

(2) fire safety depends on the "safe end" of the evacuation system—the

protected stairwells and exit doors that mark safe exiting during a fire

emergency; and (3) there is high density building occupancy which, during

a fire emergency, limits the reasonable options for evacuation that are available to building occupants. Given these assumptions, the hydraulic

model defines the building evacuation process as a two-phase process.

The hydraulic model is illustrated in Figure 1.^* The first phase, the

"start up" phase, consists of an immediate, appropriate, self-initiated

movement toward the nearest exit by the building occupants, given a decision to evacuate a building during a fire emergency [ SS , for "self

starting"]. Self-initiated movement means that the occupant does not

require any assistance from others to initiative his or her evacuation.

The second phase, the "egress" phase, consists of a deliberate progression toward the exit, with each occupant moving under his or her own

power, in tight formation with the other evacuees [SE, for "self evacuating"]. The model suggests there should be no surges or queues, just a constant use of the exit channel at or near capacity until the last

occupant safely clears the exit. In both phases, no interaction or interdependence between evacuees is considered.

^ Each of the six sections of this chapter has its figure. Each figure

maps the factors and their interrelations that are discussed in its

section. Figure 7 summarizes the factors and their interrelations for

the entire chapter.

o The reader should carefully review the introductory statement in

Appendix 1 before studying the figures in this chapter.

3 Symbols, such as SS, which appear in brackets, are used in the figures.

Each symbol represents a different factor. Each symbol introduced in

a section will first appear in the figure for that section and will

reappear in other figures as indicated in the Key in Appendix 1.

i
5*

4*

m

H—

ccm

o

oo

I—

oro

ZD

CQ

Q_

LUQ

O

O

o

<c

or lu <C —i i— I

OO CI Q_

Li- _J >-

LU QT GO O

«=£

CO

LD I GO

QT LU

LU CL

31 LU

3c Q

O

zo

o

<

or

CD

>-zc

zc o

I— c

E

3

E

x

CD 2

orZDO
The key to evacuation is the maximization of occupant discharge at the

exit or "safe end" of the evacuation route. For this reason, the

measure of overall system performance is the flow at the building exits.

1.2 NON-AMBULATORY PATIENTS

The dependent patients in nursing homes and other health care facilities

present problems during fire evacuations that violate the assumption of

independent occupant mobility, a cornerstone of the hydraulic model.

This violation arises if a building occupant is non- ambulatory , cannot

maintain the movement speed of able-bodied occupants, or interferes with

the ability of others to move on the same route. Non- ambulatory patients

may not reach the safe end without assistance from others. They may not even be able to initiate an evacuation effort because they cannot leave

a bed or a chair unassisted. Without self-initiated movement and uniform

self-evacuation, emphasis on the safe end alone is insufficient [s, for

"safe end"]

.

It is assumed that whenever non- ambulatory persons are considered, the

analysis of the evacuation process during a fire must shift from the safe

end to the "threatened end" of the evacuation route [t, for "threatened

end"] —the point from which the non- ambulatory patient who is, presumably, near the path of the fire or its products must begin his escape.

Instead of self-initiated start-up, deliberate preparation of the patient

for evacuation must be considered.

This "preparation" process involves at least two people: a non-ambulatory, therefore dependent, patient and one or more assistants or helpers

who, at the beginning of a fire evacuation of a nursing home or health

care facility, are likely to be nursing home or hospital staff and firefighters. This is illustrated in Figure 2. (It is recognized that

patients without mobility problems may be dependent on assistance for

other reasons. However this paper focuses on those with mobility

problems .

)

During the preparation process, the requirements of the self-starting

patient group [SS, for "self-starting"] are largely consistent with

the assumptions of the hydraulic model. However, the non- ambulatory

patients are dependent upon the assistance of others, and, as a consequence, they introduce several factors affecting evacuation.

The first factor is the preparation assistance required by each non- ambulatory patient [PR, for "preparation required"] . This depends on a patient's mobility status, medication, dependency on fixed life-support

system, and on prosthetic appliances to sustain movement. Preparation

covers everything from awakening a sleeping patient to dragging to safety

a comatose patient who has been wrapped in a wetted sheet.

The second new factor is the level of preparation assistance that can

be provided for each patient [PP, for "preparation provided"]. This

involves the training and competence of the helpers, such as staff, to

perform under the stress of a fire emergency, the tasks that compete for

5
>*&l*- CD

C013

.1E3EX«2 6

FIGURE_2 :

NON-AMB>LA"ORY

PATIENTS,

WHERE

(s)

IS

THE

'SAFE

END'

OF

THE

EVACUATION

ROUTE;

(t)

IS

THE

'THREATENED

END';

(SS)

is

THE

SELF-STAR-IVS

ACTION

OF

INDEPENDENT,

AMBULATORY

PATIENTS;

(PR)

IS

THE

PREPARATION

REQUIRED

OR

RECEIVED

BY

DEPENDENT

PATIENTS:

VC. PP)

IS

THE

PREPARATION

PROVIDED

BY

TRAINED

ASSISTANTS.
staff attention during an emergency, and the availability of needed

equipment. The preparation process can be ineffective if the assistant

cannot handle a wheelchair transfer or does not have a needed stretcher.

The third factor is the conditions under which preparation tasks must be

performed. Conditions such as the exposure to risks, time limitations,

the availability of intermediate fire protection systems and the layout

of the workplace can affect the patient's cooperation, the helper's performance and the levels of stress imposed on both patient and assistant.

In short, the preparation task is a collaborative interaction between

two people, one of whom, the non- ambulatory patient, is almost entirely

dependent upon the other. This collaboration, however, is influenced by

the entirely different costs and benefits each faces from the success or failure of the collaboration. These differences in outcomes and their

evaluation provide the context for many crucial decisions during

evacuation.

1.3 REMOVAL FROM THE THREATENED ZONE

When the preparation task is completed, the process of actually removing

patients begins. This is illustrated in Figure 3. At this point, the

patient population can be classified as those who can proceed toward the

exit on their own [A, for "ambulatory"] and those who cannot. The

latter, who require continued assistance, include the non-ambulatoi

y

patients [NA, for "non-ambul atory"] . The ambulatory patients are grouped with the self-starting self-evacuators who do not require

assistance during the preparation process.

The ambulatory group includes patients who are not fully ambulatory in

the sense presumed by the hydraulic model. They may move slowly, pause

occasionally to rest, or not proceed directly to the exit. Some may use prosthetic appliances which could interfere with the escape of other

evacuees. As a result, the overall speed of movement is likely to be

considerably slower than if the population was fully able-bodied and the

rate of flow will be less uniform. Moreover, the not-fully-ambulatory

patients will be less likely to "out run" the fire and its harmful

effects and more likely to be vulnerable to its effects than able-bodied

individuals. Consequently, this group, because it is too capable to

receive help all the way to safety, must be regarded as a vulnerable

patient group in a fire emergency.

The prepared patients who require continued assistance [AR, for "assistance required"] present problems during a total evacuation effort.

Each of these patients must be helped by an assistant to safety [AP, for

"assistance provided"] . Whatever the form of removal assistance—being

helped along by the arm or being pushed in a wheelchair—patients who

receive continual assistance place a substantially greater demand on

the exit channel than those who do not. Although a single wheelchair

patient, for example, may be moved as fast as an able-bodied assistant

can move, the assistant plus the wheelchair takes up more of the

7
m

»

co

h-

- z

2! I— 2: o< O

C >- C DI 25 COO Q- I— C LUO CC —J LU

CL. ID

CQ UJ

OC 2EI 2:

Ll. Ll- CO C O >—

tO 21 ^ H O CL Z *-h <C

LU I >—< O

c o

c z CL. o c

O h- CO C ht/) D Z

ID O LU

h- C -* C > I

h- LU C tO I Q_

Ll. >- _i >-

CC LU QI o to o h- I

C LU C

CO CD Si (/) Z

LU "Z. m lu o t- ooz

to >-

1—t • #> CD

C LU Cd LU

DC C O

LU Q- LU m lu cd 3: oc

Cl. CC

* O DCLU O

h- LU

Ll. QC < h-. 25 to

E

3

E

G®

2: QC

h- O

c z Q- C

H—

Lt- CO O —

«

to c z: h- o <0 «—

•

h-

>- c CC ZD O O

h- C

C >

ICf—to

LU CXL

zsz C

ASSISTANCE

PROVIDED

BY

TRAINED

ASSISTANTS.
available space in the exit route than does a single fully ambulatory

evacuee. The overall reduction in speed, increased demand for space,

and decreased flexibility from attempting to move cumbersome objects

through constricted channels can seriously disrupt the overall continuity

of the outward flow. Substantial queuing can be expected to occur as temporary blockages develop while wheelchairs, for example, are guided

around corners or through fire doors.

Although evacuation diminishes each patient's exposure to risk at the

threatened end of the route, it also introduces risks of its own:

injury enroute, or illness due to overall exposure at the safe end.

These possible consequences will be treated as acceptable costs, given

the benefits (e.g., survival) of efficient and effective evacuation.

Nevertheless, given the elderly and debilitated status of occupants of

nursing homes and health-care facilities, the relative magnitude of

these costs (risks) is an open question.

1.4 SUPPLY OF PREPARATION MANPOWER

Evacuation assumes available preparation and evacuation manpower. The

time spent covering the distance to get manpower where it is needed is

critical to the success or failure of any evacuation effort. For many

building fires, the required personnel probably will be initially located

a considerable distance [d, for "distant point"] from the fire. Of

course, if nurses or orderlies are in the immediate vicinity of the

fire, their presence is likely to lead to earlier detection and a subsequent minimization of the threat. The initial supply of preparation

manpower [IS, for "initial supply"] is shown in Figure 4. This activity

must precede the initiation of the preparation process [PP].

The analysis of supplying preparation manpower requires new concepts.

One of these new concepts is the "most threatened patient"—the individual

who is most critically affected by the threat of flame, smoke, toxic

fumes, or heat. Once the person is prepared and evacuated, another

individual becomes the most threatened patient. If the threat is developing along more than one front (e.g. along two separate corridors),

there will be a succession of most threatened patients for each fire

front. The succession may not always be clear. Nevertheless, there

will always be someone on each fire front who, by virtue of his or her

proximity to the threat, is more threatened by it than the others.

A second concept is manpower distribution. This is a measure of where

available assistants are relative to the location of the most threatened

patients. This concept addresses the number of available assistants,

their effective distance(s) from the most threatened patient(s), and

the number of intervening opportunities occurring enroute. Intervening

opportunities include calling the fire department, seeking more help,

or closing doors to patient rooms. (The latter can significantly delay

the delivery of preparation manpower to the most threatened patient.)

The number of intervening opportunities generally will diminish as the

fire develops. However, the level of uncertainty associated with the

delivery of preparation and evacuation services may increase as the

9
i

"x

10

FUiLito^

4.;

SUPPLY

OF

PREPARATION

MANPOWER

,

WHERE

(d)

ISA

'DISTANT

POINT'

AT

WHICH

THE

ASSISTANT

IS

INITIALLY

LOCATED;

US,

:c

the

INITIAL

SUPPLY

OF

MANPOWER;

AND

(PP)

IS

THE

PREPARATION

PROVIDED

BY

TRAINED

ASSISTANTS.
fire develops. That is, as smoke builds up, doors are closed and

responsibilities are shared by more people, the determination of where

patients are located, who has been evacuated, how much time is left, or what risks lie behind a closed door becomes more difficult, hence more

uncertain.

Because of uncertainty, the manpower supply process is not the kind of

task that can be easily conceptualized or easily performed in a prescribed manner. The evacuation process offers the assistant no vantage

point from which to fully grasp the progress of the situation he is in.

This makes the tenuous bond between the assistant and the patient pivotal

to the success or failure of the entire evacuation process.

Because time is the key measure of performance, the idea of initial

response time will be introduced to represent the interval between the

decision to evacuate and the arrival of an assistant at the side of the

most threatened patient. Thus, the helpers' response times for the

succession of next most threatened patients can be determined. Since

response times depend on the location of the assistants (e.g., staff)

and patients at the time the decision to evacuate is made, it is possible that the actual response time of the first assistant might take a substantial portion of the required total time available to able-bodied

occupants for evacuation within the hydraulic model.

1.5 RESUPPLY OF MANPOWER

With an infinite supply of preparation manpower, each assistant would

have one patient to prepare and evacuate. However, in practice, the

supply of preparation manpower is limited. Therefore, not one but more

than one patient will have to be helped to evacuate by each assistant

who is willing and able to return to the threatened end of the evacuation route. The resupply of manpower is illustrated in Figure 5. After

escorting a dependent patient to safety [AP, for "assistance provided"]

,

each assistant returns to prepare and remove other patients exposed to

the continuing threat [RM, for "resupply manpower"]. One aspect of this

process will be the opportunity for "rest and recovery" [R&R, for "rest

and recovery"] at the safe end of the route. As the fire threats

increase, this opportunity becomes more necessary. Fatigue and firerelated stressors can sap the endurance of the helpers. This, in turn, can crucially affect the rate at which manpower can be resupplied to

patients requiring assistance. Thus, by coupling the resupply manpower

rate [RM] with the initial supply of manpower [IS], an overall manpower

supply rate [MS, for "manpower supply"] can be established. The initial

response time plus the overall manpower supply rate provides an estimate

of the overall level of preparation and evacuation service that can be

provided in a given emergency situation.

If manpower is resupplied by assistants returning to the threatened end

of the evacuation route, there is an "evacuation circuit" — a two-way

flow between a most threatened patient, a zone of safety or refuge, and

the next most threatened patient. The length of this circuit is a function of the distance between threatened patients and the nearest

11
>1

+»0**» <0

</) E3E3EMBX0

lu

m

m . ^ ID

CD oo I— I— <c Z Lx_ h- O OO Z -« <c inm lu < cc M I< < I— CL

CL cl I— U_ CL O LU

>- cl CO (/) Qh- Q C_) I

UJ LU Z Q Lu LU O C CL LU CL

cl

mh- or

LU

O CD I— Ll Z LU < (/) >

hU 1 t/) Li- Cl — O Q_ OO ID oo o m C I—

oc Z Q lu O LU 3 >—< CL O I— >—< Q- < DZ id a< UUJI C O' > -J

LU >* cC

cl f— LU LU o in > hf— oO LU

(/) LU

x *-< cl hOO

CL Z *-H < c

LU l/) z DC LU —

LU CL

nz

q 3 LU z n: c

CL CL oC Z

cl <C

DC o LU3 >- O _J

CL CL

Q- «< IDm o cI—t

>- I

I t—I

CL Z CL •—•

ZDm lu

lu =n

CL I—

12
unobstructed exits. The length should diminish as more patients are evacuated. The time required to cover the evacuation circuit, including

rest and recovery at the safe end, should determine the rate at which

assistants can be resupplied to the next most threatened patients.

The concept of "counterflow" is introduced to describe assistants

returning to help additional non-ambulatory patients. It will be

important to determine whether the shuttling between the safe end and

the threatened end of the route reduces the carrying capacity of the

channel and if counterflow actually provides supplementary manpower when

it is needed. This determination is important because efficient reuse

of limited manpower plays a pivotal role in the success or failure of

the evacuation effort and in the overall cost of that effort in terms

of injuries and other losses.

1.6 MANPOWER ORGANIZATION

Five steps in patient evacuation have been covered: (a) the supply of

qualified assistants, (b) patient preparation, (c) patient removal/evacuation, (d) brief rest and recovery of the assistant, and (e) the resupply of assistants. Unfortunately, the efficient execution of these

operations will not result necessarily in the successful evacuation of

large numbers of non-ambulatory patients. If there is limited supply

of assistants and if too much effort is devoted to the first few

patients, then less time will be available for other dependent patients.

As the fire progresses, these conditions jeopardize the successful

evacuation of these patients.

This situation can be alleviated somewhat if the supply of manpower

increases as the fire develops. It is assumed that lowest numbers of

assistants usually will be available at the beginning of the evacuation

process and their numbers will increase as people, including additional

staff and firemen, respond to the fire emergency. If this is the case,

then initial preparation and evacuation efforts should be limited to the

provision of a minimal, but sufficient, level of service to as many

threatened patients as possible, leaving to newly arriving personnel

the provision of the remainder of the assistance required by each

evacuee.

What has been described is called "task differentiation." It is

illustrated in Figure 6. The available supply of assistants [IS] devote

their efforts to patient preparation [PP] and to providing partial assistance [PA] by removing patients from the immediate sources of threat.

That is, prepared patients receive enough limited assistance [AR^, for

"partial assistance received"] in order to be evacuated to an intermediate point of refuge [i, for "intermediate"] which removes them for the

immediate threats but leaves them for the time being less threatened but

still in the threatened zone. The later supply of assistants concentrates on continuing the evacuation assistance [CA, for "continuation

of assistance”] required to remove patients from the threatened zone

[i] to safety [AR„, for "continuation of assistance received"]. This

differentiation of tasks allows the initial assistants to immediately

13

r.,
O

O 00

O LU

—, > >- oo £ £*<? <ua C*. LU Li- h- ce: (/> o

14
resupply manpower [RM] to prepare the next most threatened patients

after a momentary opportunity for rest and recovery [R&R].

Task differentiation requires the provision of intermediate protection,

like a closed fire door, at the intermediate holding position. The most

effective way to provide intermediate protection is to use a patient room

or some other enclosed area with its doors closed as a holding area.

There are advantages and disadvantages to task dif f erentation. The

advantages are: (1) service is delivered to more threatened patients;

(2) the use of means of egress by assistants is reduced; (3) assistants

who are familiar with the situation remain where that knowledge is most

useful; and (4) it takes full advantage of the later arrival of more

help.

The major disadvantage of task differentiation is there is greater

exposure to risk by assistants who initially prepare and partially evac- uate patients [AR] compared with helpers who primarily complete the evac- uation of patients [AR

2

] . To reduce the risks of overexposed assistants,

it is recommended that they be allowed to occasionally accompany a highly

vulnerable patient all the way to safety. However, managing such a rotation of personnel under emergency conditions—even if this involves

trained staff—can be difficult. Difficulty will arise, for example, if

there is no previously established "chain of authority" to facilitate the

shifting of responsibilities among staff. Moreover, in the commotion of

an actual evacuation, it is unlikely that a chain of authority will

emerge.

There is another disadvantage of task differentiation. An established

evacuation plan can run afoul when the services of persons who are unfamiliar with the plan are introduced into the evacuation process.

Such persons would include visitors to the building of passers-by "off

the street." Unless the role of these outsiders is anticipated, the

efficacy of drills and plans in an actual emergency will be serious

compromised.

Whether or not the proposed procedures can be successfully implemented

under emergency conditions, more consideration must be given to how an evacuation is organized and how responsibilities are allocated so that

the overall level of performance during a particular evacuation effort

is optimized.

i n _sum, this chapter has presented the major factors involved in evacuating non— ambul atory patients during hospital and nursing home fires.

Figure 7 summarizes the relations among all of these factors. Successful

implementation of the complex procedures described in this chapter seems quite problematic under emergency conditions. Nevertheless, it appears

that more consideration must be given to how an evacuation is organized

and how responsibilities are allocated if the overall level of performance during particular evacuation effort is to be optimized.

15
>»m

16
2 THE EVACUATION PROCESS

In this chapter, the overall evacuation process described in Chapter 1 is reconceptualized into five sequential phases in order to provide

a framework for assigning priorities to factors that can control the success or failure of the evacuation process. The five phases are (1)

the manpower supply phase, (2) the patient preparation phase, (3) the

patient removal phase, (4) the rest and recovery phase, and (5) the

manpower resupply phase. The reconceptualization is not a model of

an evacuation system. Rather, it suggests classes of variables which

such a model must include and measures by which the effectiveness of

evacuation systems might be evaluated.

Each phase is a set of activities. Collectively, the activities make a unified contribution to the evacuation of non-ambulatory patients from

fires in health care facilities. It is assumed that the time period

during which each phase makes a decisive contribution to the success

or failure of the evacuation effort as a whole can be quite limited.

Based on this assumption, the most critical portion of each phase is

defined as the minimum elapsed time required to complete all activities

necessary to permit the initiation of the next phase of the evacuation

process. The most effective portion of each phase is defined as the

total elapsed time required to assure that no patient's exposure to risk

is increasing. This is the point at which the continuation of a given

set of activities begins to assume a lower priority than initiating

another set of activities. Obviously, the critical and effective portions of each phase of the evacuation process are both related to the

development of the fire and the efficiency with which all evacuation

tasks are performed.

This chapter will examine each phase of the evacuation process with

respect to (1) behavioral and environmental factors that constrain or facilitate performance, and (2) the critical decisions or trade-offs

involved. For each phase patient, building and staff factors are discussed.

(a) Patient Factors - The non- ambulatory status of a patient

in a hospital or nursing home fire is the driving force

behind any evacuation effort. Minimizing the threat to

these occupants is the primary goal of both an evacuation

effort and of improvements in staff training, fire protection, or building design that might facilitate the

evacuation process.

(b) Building Factors - Ordinarily, a building provides

relatively stable "opportunities" for human activity.

However, in a fire situation the stability of these

opportunities rapidly diminishes. Unlike activities,

fires do not occur within buildings. Rather, a fire

changes the building itself; it must be considered as a "progressive change in the conditions of occupancy" of a building. Activity is necessarily disrupted in a fire
situation; you cannot always stay where you are and cannot easily go where you wish. What were once opportunities can become "obstacles" to escape or evacuation*.

(c) Staff Factors - During a fire emergency, the staff and

other assistants must capitalize on the remaining opportunities in order to evacuate as many threatened patients

as possible..

(d) Staff Decisions - The decisions, trade-offs, and options

exercised by the staff are the key determinants of the success or failure of an evacuation effort- Because of

the significance of staff decisions, during each phase

of the evacuation process, this factor is listed as a separate category.

For each phase, examples of each factor that should be considered in

any further analysis of that phase are listed- The list of examples

appears as Figures 8-12, one figure for each of the five phases.

2.1 MANPOWER SUPPLY PHASE

If a fire starts in a nursing home or health care facility with non- ambulatory patients, the need arises for persons to assist them during

the evacuation process- The act of going to the aid of a non- ambulatory

building occupant is the manpower supply phase of the evacuation process.

It begins when the decision to commence the evacuation process first

reaches a potential assistant, and continues as long as assistants

continue to reach threatened patients.

The most critical portion of the manpower supply phase is the time

between the decision to evacuate and the arrival of the first assistants) at the side of the most threatened patient(s)- The most effective portion of this phase of the evacuation is the time between the

decision to evacuate and the arrival of a sufficient number of assistants to evacuate all threatened persons without further loss of life

or serious injury- This represents a point beyond which the arrival

of additional manpower adds less and less value to the overall evacuation effortFigure 8 lists examples of patient, building, staff and staff decision

factors to be considered in any further analyses of the manpower supply

phase.

2-2 PATIENT PREPARATION PHASE

Once a decision to evacuate a portion of a building is made, a threatened occupant may complete certain incidental activities before

starting toward an exit. For an alert, autonomous occupant this is

called the "start-up" period—a time to put on a robe, gather personal

18
Figure 8. MANPOWER SUPPLY PHASE: Examples of Factors

In any further analysis of the manpower supply phase, the following factors must be considered:

Patient Factors :

- The number of dependent, non-ambulatory patients or other occupants of the fire

zone who are directly exposed to the threats of flame, smoke, toxic fumes or

heat.

- The degree of dependency of the threatened patient population in terms of the

numbers of assistants and any special equipment that initially might be required

to prepare them for evacuation.

- The locations of dependent patients with regard to their respective distances from effects of the fire, potential assistants, any special equipment that might be needed, and from an intermediate point of safety or the safe end.

- The degree to which a given patient's location, condition and exposure to risk

are apparent to a potential assistant using sensory cues or physical signals.

Building Factors :

- The location of the fire; the rate, severity and direction of fire development;

and the spread of smoke, toxic fumes or heat.

- Spatial relationships between patient rooms, corridors, points of entry, staff

work stations and other service areas within or adjacent to the fire zone.

- The number and physical condition of potential routes of access to the most threatened patients -- through corridors, adjacent rooms, exterior windows,

etc.

- Protective obstructions along the route(s) of access to the most threatened

patients -- closed fire doors, operating sprinklers, wire glass, etc.

- The distances between the most direct route of access to the most threatened

patients and devices required for performing intervening tasks enroute —

phones, pull-boxes, extinguishers, equipment storage, etc.

- The reduction in visibility and air quality and the distortion of orientation

cues introduced by smoke, flame, sprinkler showers and closed doors.

Staff Factors :

- The number of staff assistants initially in or near the fire zone at the time the decision to evacuate patients is made.

- The locations of the available assistants with respect to the most threatened

patients.

- The available assistants' familiarity with the facility (e.g., layout, location

of special equipment, and the institutions 's fire emergency procedures) and the

patients.

- The speed with which the assistants are able to proceed toward the most threatened patients, including the time spent to perform intervening tasks enroute.

- The ability of the staff to anticipate the appearance of an actual fire emergency and to evaluate fire threat development.

- The establishment and use of recognized and accepted chains of command.

Staff Decisions :

(After learning of a decision to evacuate patients):

- Whether to begin immediately to evacuate patients or to send an alarm, confirm

the existence of the fire, fight the fire, conclude ongoing activity or flee.

- Whether to proceed directly to the fire zone or to perform intervening tasks enroute—closing doors to patient rooms, awakening other patients, sending

an alarm, etc.

- Whether to proceed to the fire zone first or to gather special equipment along

the way — wheelchairs, stretchers, oxygen masks, etc.

- Which route should be taken to which point on the fire front (a function of one’s past experience in using different parts of the facility and of one's

perception of the location and severity of the fire).

- Who are the most threatened patients and where should one look for them.

- Whether or not to enter spaces that are filled with smoke or to open closed

doors encountered near the point of origin.

- Whether or not any locations are beyond searching or any patients are beyond

saving.

19
belongings, or the like. For most pre-evacuation tasks, their objective

benefits may be less than their potential cost in terms of increased

exposure to fire threats.

The task of either protecting the patient from the immediate effects of

the fire or getting them ready to be evacuated from the threatened zone

is the patient preparation phase of the evacuation process. The most

critical portion of the patient preparation phase is the time between

the arrival of the first assistant(s) and the completion of the preparation tasks for the most threatened patient(s). The most effective portion begins with the arrival of the first assistant(s) and continues

until all occupants whose safety is dependent upon protection or removal

have been prepared for movement. This is the point at which the demand

to remove prepared patients is greater than the demand to prepare additional patients. Whatever the difficulty in establishing the sufficiency

of manpower during an actual evacuation, the actual utility of allocating

limited manpower to preparing marginally threatened patients will be central to understanding the success or failure of the evacuation process.

Figure 9 lists examples of patient, building, staff and staff decision

factors to be considered in any further analysis of the patient preparation phase.

2.3 PATIENT REMOVAL PHASE

Only after a dependent patient has been fully prepared for movement can

the actual act of removing them from the threatened zone be considered.

Unlike the manpower supply and patient preparation phases, the patient

removal phase may proceed in stages. For example, the most threatened

patients may be evacuated to an intermediate zone which affords limited

protection but decreases the threat to the patient. This characteristic

of the patient removal phase makes it a difficult phase to explicate.

The most critical portion of this phase begins with the movement of the

most threatened patient(s) away from the fire front and ends when those

patients have been removed from the immediate threats of flame, smoke,

toxic fumes or heat. The most effective portion begins with the movement

of the most threatened patient( s ) and continues until all occupants of

the threatened zone have been either removed from the likely effects of

the fire or protected from the fire threat by bringing that threat under

control

.

Figure 10 lists examples of patient, building, staff and staff decision

factors to be considered in any further analysis of the patient removal

phase.

^ This section emphasizes evacuation. However,

is staying in one's room with the door closed

20

another legitimate option

(see Section 5.3.1).
1

Figure 9. PATIENT PREPARATION PHASE: Examples of Factors

In any further consideration of the patient preparation phase, the following factors must

be considered.

Patient Factors :

- Requirements for sustained mechanical life support or therapy (e.g. , intravenous blood, medication, heart monitors).

- Requirements for and the availability of life-support, transport and prosthetic

equipment to enable sustained movement with or without assistance.

- Susceptibility to a serious deterioration in medical condition due to sudden changes in environment or movement (e.g., post operative shock, pneumonia).

- Awareness of the nature of the emergency and ability to cooperate with an assistant in the preparation process (a function of mental alertness,

senility, sedation, medication, etc.).

Building Factors :

- The availability of an adequate workspace that is free from the immediate

effects of the fire and from the congestion caused by the evacuation process.

- The effects of smoke, toxic fumes and heat on visibility and air quality.

Staff Factors :

- Proficiency in performing all required preparation tasks properly and efficiently.

- Personal characteristics required to perform tasks without strain or injury to the staff member.

- Cumulative effects of pre-emergency workload on alertness, endurance and ability to perform under stress during an emergency.

- Effects of evacuation tasks on energy expenditure and fatigue.

- The effects of personal and social characteristics (e.g., fear, disorientation,

guilt, compassion or disdain for certain patients) on attitudes and motivation

during a fire emergency.

Staff Decisions :

(After arriving at the side of the most threatened patient):

- Whether to prepare a patient for removal or to attempt to protect them in place.

- Whether or not to disconnect a patient's life-support systems — intravenous nutrition or blood supplies, catheters, heat monitors, oxygen, etc.

- Whether to prepare a patient to be evacuated by an assistant or to move on

his or her own.

- Whether or not to use a bed, wheelchair, stretcher or other device to transport

the patient (a function of estimated manueverabi 1 ity, channel capacity, 'manpower

availability and energy expenditure required).

- Whether or not to salvage any of the patient's personal property.

|

I

I

1 21
Figure 10. PATIENT REMOVAL PHASE: Examples of Factors

In any further consideration of the patient removal phase, the following factors must be considered:

Patient Factors :

- Mobility status of prepared patients in terms of the manpower or equipment

needed to sustain movement (a function of weight, stature, medical condition,

cooperation, etc.).

- The locations of non-ambulatory patients with regard to their respective

distances from the effects of the fire, places of safe refuge or exits.

- The maximum effective speed at which movement can be sustained on an unobstructed route, with or without an assistant.

- The effects of stamina, endurance and determination on the patient's need to pause to regain strength enroute to the exit or refuge zone.

- Total numbers of evacuees requiring removal at any given point in time.

- Excess demands for space within the exit channel resulting from the use of assistants and life-support, prosthetic or transport equipment.

- The patient's exposure to stressors or injuries.

- The impact of awareness, familiarity, confusion or fear on potential disori- entation or resistance in the face of ambiguous cues and strange circumstances.

Building Factors :

- Spatial relationships between patient rooms, treatment or activity areas, corridors, refuge zones and unobstructed points of egress, within or adjacent

to the fire zone.

- The number and condition of potential egress routes — through corridors,

adjacent rooms, stairways, exterior windows, etc.

- The capacity of the egress route(s) with regard to the spatial demands of evacuees accompanied by assistants or encumbered with equipment.

- Obstructions to clear passage caused by equipment parked or temporarily stored within the egress route -- wheelchairs, food carts, crash carts, cleaning

equipment, etc.

- Architectural barriers and excessive demands on human energy along the egress route -- excessively slip-resistant or slippery surfaces, heavy doors, rarnps, stairs, narrow passageways, corners, etc.

- Height of the fire floor above ground level.

- The location of the fire within the fire floor.

- The rate and direction of fire development and the spread of smoke, toxic

fumes or heat.

- The reduction of visibility and air quality and the distortion of orientation

cues introduced by the effects of the fire.

- Choice points among alternative routes one encounters.

- Reduced route options and distorted orientation cues introduced by system failures -- power cut off, blocked exits, fire damage, etc.

Staff Factors :

- The number of staff assistants within the fire zone at the time removal begins.

- The actual and perceived proximity to the fire zone of additional assistants

at the time removal begins.

- Familiarity with the physical layout of the facility, the location of primary

and alternative exit routes, the locations of intermediate refuge zones, the

spatial habits of the patients, the proper operation of transport equipment,

and the institution's fire emergency procedures.

- The speed with which assistants are able to move evacuees away from the

fire or its threatening effects, including time spent performing incidental tasks enroute.

- Human energy expenditure and fatigue resulting from the magnitude of the removal effort (in terms of the numbers of evacuees and distance) and from the spe- cific techniques used to transport dependent patients.

- Asphyxiation or injury resulting from exposure to flame, smoke, toxic fumes

or heat.

22
Figure 10. PATIENT REMOVAL PHASE: Examples of Factors (Continued)

- The degree to which experience and training has anticipated the appearance

of an actual fire emergency and increased the assistant's ability to interpret cues to the nature of threat development.

- The implementation of lines of authority and communication with regard to the allocation and coordination of assistants to priority tasks (task differ

entiation), the validity of information about the progress of the fire and

the evacuation effort, and the separation of conflicting activities like firefighting and patient removal.

Staff Decisions

(Once the most threatened patient(s) have been prepared for removal):

- Whether to move the prepared patient all the way to a safe zone, to remove them from immediate threats only, or to prepare other patients (a function of estimated manpower availability and the immediacy of the risk to the various patients).

- Whether to assist partially ambulatory patients or to let them try to make

it on their own.

- How many assistants to allocate to each non-ambulatory evacuee.

- Which route will most efficiently lead to a protected exit or refuge zone

(a function of the estimated location and progress of the fire and past experience in using different parts of the facility).

- Whether to proceed directly to an exit or to perform intermediate tasks enroute -- closing doors, alerting other patients, assisting other patients

or assistants, etc.

- Whether to stay with a dependent patient in the face of adversity or to abandon and sacrifice them.

23
2.4 REST AND RECOVERY PHASE

Energy expenditure and the effects of stress can be expected to reduce

the ability of assistants to perform at peak efficiency over time.

Suspending the evacuation tasks long enough to regain their ability is

the rest and recovery phase of the evacuation process. Unlike the other

phases, which are continuous or proceed in stages, the rest and recovery

phase is intermittent—it is a series of brief episodes which might

increase in frequency and duration as the evacuation continues.

The most critical and effective portions of this phase are linked to the

progress of the preparation, removal, and resupply phases. The most

critical portion begins when the first assistant stops to service his or her own needs, rather than those of a dependent patient. It ends either

when the most threatened patients are removed from immediate danger or when enough additional assistants are available to assure their successful removal. With abundant manpower, there may be no rest and recovery

phase if all threatened patients can be serviced before any assistant is

overtaxed. With limited manpower, the need for rest and recovery may

preempt the evacuation process with a resulting loss of life or serious

injury to patients. Moreover, an assistant who refuses rest and recovery

may become exhausted, injured or killed. Rest and recovery, then, is a necessity. The issue is whether the frequency and duration of rest and

recovery episodes can be minimized by each assistant, without jeopardizing him or her, until the most threatened patients are out of

immediate danger or until there is enough manpower available to aid

non-ambulatory patients.

The most effective portion of this phase ends when all dependent

occupants of the threatened zone have been or are assured of being

sufficiently removed or protected from the fire to eliminate the

likelihood of further injury or loss of life. This means that it is

most effective when the frequency and duration of rest and recovery

activities are such that they are minimally disruptive to the most

effective portions of the other phases of the evacuation process.

Figure 11 lists examples of patient, building, staff and staff decision

factors to be considered in any further analysis of the rest and recovery

phase.

2.5 MANPOWER RESUPPLY PHASE

The need to recycle the manpower available to perform evacuation tasks

is directly related to the limitations on the intial supply of preparation manpower. The more people available to assist in the evacuation

process, the less need there is for any of them to enter the fire zone more than once. Under ideal manpower conditions there would be no need

for a resupply phase. With a limited initial supply of manpower, the

manpower resupply phase becomes necessary.

The most critical portion of this phase begins when the first assistant

reenters the threatened zone and ends when sufficient manpower is at the

24
Figure 11. REST AND RECOVERY PHASE: Examples of Factors

In any detailed consideration of the rest and recovery phase, the following factors

must be considered:

Patient Factors :

- The combined effects of the initial distances from protected exits or refuge

zones, body weight, stature, levels of cooperation, medical condition and

special equipment needs on the workload handled by staff assistance.

Note that the asphyxiation, injury or exhaustion of a patient due to excessive

energy expenditure, traumatic episodes, or exposure to the stressful effects

of the fire during the preparation or removal phases are not "factors" in the evacuation process, but rather indications of its partial failure.

Building Factors :

- Spatial relationships between the "threatened end" and the "safe end" of the evacaution circuit and any other points of safe refuge within or near the fire zone.

- The number and condition of alternative routes between the area of fire involvement and refuge zones.

- The amount of space, level of protection, and supply of oxygen or fresh air available in the refuge zones.

- The combined effects of the intensity and distribution of flame, smoke, toxic

fumes and heat, within or near the fire zone.

- The cumulative effects of the energy demands of the evacuation circuit —

stairs, ramps, long distances, heavy doors, excessively slip-resistant or slippery surfaces, etc.

Staff Factors :

- Smoke inhalation, injury, exhaustion due to excessive energy expenditure,

trauma, or exposure to thermal or toxic stressors during the supply, prepara- tion or removal phases.

- The cumulative effects of the allocation of individual workloads in terms of the rates of energy expenditure and the duration of exposures to the direct effects of the fire.

- The cumulative effects of the specific patient preparation and transport techniques used with respect to total energy expenditure and fatigue.

- Proper utilization of auxiliary breathing apparatus -- oxygen masks, etc.

- The amount of manpower available to service the needs of the remaining threatened patients.

- The effect of individual respiratory, metabolic, cardiac, allergenic or psychological conditions on endurance levels.

Staff Decisions :

(After reaching safe refuge following exposure to the effects of the fire):

- Whether or not one has the ability to perform any of the additional preparation

or removal tasks that are needed.

- Whether assistants' contribution to the evacuation effort will be greater if they pause to regain some of their strength or if they reenter the fire zone immediately (a function of the estimated ratio between the manpower that is available and the magnitude of the task ahead).

- Whether or not to give up the security of a safe refuge by exposing oneself to further risks in the fire zone.
side(s) of the most threatened patient(s) to assure their successful

removal from the immediate effects of the fire. Similarly, the most

effective portion of the manpower resupply phase begins when the first

assistant reenters the threatened end and continues until enough assistants are engaged in the tasks required to remove or protect all non- ambulatory patients of the threatened zone from the likelihood of further

injury or loss of life. Precautions may be necessary to assure that an oversupply of manpower does not interfere with the efficient conduct of

evacuation tasks and that assistants do not unnecessarily expose themselves to risk by reentering the fire zone after their services are no longer needed or their ability to function effectively has been

seriously impaired by their arduous activities.

Figure 12 lists examples of patient, building, staff and staff decision

factors to be considered in any further analysis of the manpower resupply

phase.

26
Figure 12. MANPOWER RESUPPLY PHASE: Examples of Factors

In any further consideration of the manpower resupply phase, the following factors must

be considered:

Patient Factors :

- The number of dependent, non-ambulatory patients within the fire zone(s) who

remain exposed to the threats of flame, smoke, toxic fumes or heat.

- The conspicuousness of each remaining patient's location and situation using

visual, auditory, tactile or automated sensing methods.

- The apparent condition of those patients who remain -- beyond saving, in need

of help, likely to get out on their own, etc.

- The locations of the remaining dependent patients with regard to their respec- tive distances from the effects of the fire, firefighting activities, and assistants who are ready to return to the fire zone.

Building Factors :

- Spatial relationships between patient rooms, corridors, points of entry and exit, and zones of safe refuge, within or adjacent to the fire zone.

- The number and condition of the potential routes of access to the next most threatened patients-- clear, deteriorating, impassable, etc.

- The availability of intermediate protection or protective equipment along the evacuation circuit — streams of water, closed doors, breathing apparatus,

etc.

- The location of the fire.

- The effects of control systems on the development of the fire and the spread

of its effects -- firefighting, sprinklers, venting, pressurization, etc.

- The effects of the intensity of flames, smoke, toxic fumes and heat on visibility and air quality within the fire zone.

Staff Factors :

- The amount of manpower available and able to service the needs of the remaining threatened patients.

- The rate at which additional assistants and firemen are responding to the fire

zone.

- The condition of the assistants available to return to the fire zone (a func- tion of the effects of prior workloads and the adequacy of the rest and recovery

period).

- The effectiveness of lines of authority and communication in maintaining a valid "reading" of conditions within the fire zone; allocating manpower to the appropriate high priority preparation and removal tasks (task differentiation);

and coordinating the concurrent activities associated with evacuation, fire- fighting, and recovery or first aid.

- The psychological impact of the immediately preceding experiences within the

fire zone on an assistant's willingness to return.

Staff Decisions :

(After determining that they have the ability to reenter the fire zone):

- Whether or not aqy further evacuations are necessary (a function of the estimated

progress of the fire).

- Whether or not additional assistance will be needed to complete the necessary evacuations (a function of the estimated manpower supply and patient demand).

- Which route should be taken to the next most threatened patients (a function

of prior experience in the fire zone).

- Which are the next most threatened patients (a function of knowing who has been removed and who hasn't).

- Whether additional risks are greater or less than the chances of success.

- Whether or not one might be held personally accountable for any of the successes

or failures of the total evacuation effort.

27
3. EVACUATION AS A SYSTEM

This chapter addresses the possible relationships among the five phases

presented in Chapter 2. These five phases identify and classify the

activities for which any model of the evacuation process must account.

Building on certain patterns among the patient, building and staff

factors which reoccur throughout Chapter 2, this chapter elaborates

these patterns as "first approximations" of the functional relationships

that will be required to link the five phases of the evacuation process

together into a total evacuation system. No such models of evacuation

systems currently exist and such a model will not be developed in this

chapter. Rather, this chapter will only suggest some classes of variables which such a model must include and some of the measures by which

the effectiveness of evacuation systems might be evaluated.

One of the reasons for not carrying the model building process further

at this time is that the proper basis for interrelating the five phases

is not clear. Possible relationships between the five phases of the

evacuation process are largely a function of the point of view from

which the process is analyzed. For example, from the perspective of the

individual patient, the issue is simply one of evacuating the patient

fast enough or protecting him or her well enough to avoid death or injury. Thus manpower supply, patient preparation and patient removal

can be treated as discrete tasks, performed serially on a patient-bypatient basis, and measured against a continuous time function. However,

looking at the patient population of the fire zone as a whole, the issue

becomes one of assuring that services are delivered in direct proportion

to each patient’s exposure to the effects of the fire. This would mean

that no patient’s immediate needs would remain unmet while less

threatened patients were being helped. Here there is less concern for

the sequence of discrete phases and more concern for decisionmaking

and task differentiation within the preparation and removal phases.

If the analysis centers on the building rather than on the patient, the

central concern shifts to the maximum utilization of the exit channel

that can be sustained without queuing. From this point of view, the

restrictions that channel width and distance place on the manpower

supply and patient removal phases are the most critical.

Finally, from the individual assistant's point of view, the major concern

is to minimize expenditure of energy and exposure to stress during the

preparation and removal phases and to maximize the opportunity for rest

and recovery whenever necessary. This is in contrast to a view which

considers the group of assistants as an integrated team. Here the

emphasis is on the maximum amount of work done per man-minute. This

emphasis is contingent on managing the flow of information and manpower

between the preparation, removal and resupply phases of the evacuation

process.

Since there is too little data to support the assumptions of any of the

viewpoints, one cannot determine how the five phases should be inter28
related in order to best represent the evacuation process as a single

system. The development of a definitive model, then, will have to await

further research and post-incident investigation (see Chapter 5).

3.1

RELATIONSHIPS AMONG THE FIVE PHASES OF THE SYSTEM

From the various patient, building, and staff factors that were linked

to the evacuation process in Chapter 2, certain patterns emerge. In an attempt to simplify this complex catalog of variables and to abstract

their essential features, five system parameters are presented as a starting point for the modeling of evacuation systems for non-ambulatory

patients in health care facilities.

3.1.1 Fire Development

Understanding the process of fire development is a precondition for the

development of a capability for designing or evaluating an evacuation

system that is responsive to the needs of non-ambulatory health care patients. Of greatest concern are the changes in the conditions of

occupancy as a fire spreads under various material (fuel) and architectural (layout) conditions. In addition to the toxic and thermal effects

of the fire, the effects of fire and its products on visibility and on orientation cues within the building are of concern.

3.1.2 Weighted Mobility Status

The speed with which dependent patients and staff assistants can move on their own or as pairs is critical. Among the important aspects of mobility status are the patient's psychomotor skills, the encumbering effects

of life support and prosthetic equipment, and the patient's ability to

cooperate. A goal of modeling evacuation systems should be measuring

dependencies and encumbrances in order to assign weights to the mobility

characteristics of non- ambulatory patients and their assistants as ratios

of the mobility characteristics in independent, ambulatory populations.

3.1.3 Spatial Distribution

The respective locations of dependent patients and prospective staff

assistants at the time the decision to evacuate is made, and the layout,

design and conditions of the routes that link them to each other, to

rooms, and to protected exits or refuge zones, are critical to the

performance of an evacuation system. By describing the functions of

the institution, the training of the staff, and the plans for evacuation

in terms of the spatial behavior of those who require and provide assistance, there will be a basis for deriving travel times from distances

under normal and emergency conditions. With an ability to calculate

effective travel times and weighted channel capacities, critical performance factors like queuing can be explicitly measured (weighted channel

demand minus weighted channel capacity). This framework also permits

the explication of other factors that are amenable to interpretation

as functions of time.

29
3.1.4 Task Proficiency

The ability of assistants to perform tasks and to operate equipment

effectively (in terms of service to dependent patients) and efficiently

(in terms of expenditures of their own resources) contribute to successful or unsuccessful performance of an evacuation system. The total

amount of staff energy and time that must be expended on activities and

tasks for their proper execution is of particular concern. In effect,

determining the trade-offs between the amount of work done and the

ability to do additional work is central to understanding staff performance during the evacuation process.

3.1.5 Manpower Organization

How reliable information about the fire, the patients, and the progress

of the evacuation is delivered to the points at which critical decisions

are made during an evacuation will have to be made clear. Of central

importance are the ways in which information becomes available to and

is corroborated by those making decisions and the ways in which those

decisions are subsequently translated into courses of action within

or near the fire zone. Thus, issues like chains of authority, manpower

supply (especially undermanning and overmanning) and standardized signal

systems must be considered because these influence the establishment of

priorities, the division of responsibilities (task differentiation),

and the allocation of manpower. An explicit formulation of the communication processes should account for the major sources of judgmental error during evacuations.

3.2 SYSTEM PERFORMANCE MEASURES

Once the full implications of the five system parameters in Section 3.1

have been clarified, we qan begin to post measures of total system

performance. One such measure might be a "removal rate": the rate at

which dependent patients can be removed from a fire zone without queue

formation enroute. It would be measured in linear feet per minute from

the habitable point closest to the origin of the fire. This measure

would aggregate supply and replacement rates of assistants, the preparation times of most threatened patients, and the rates at which prepared

patients can be removed from the threatened end of the evacuation route.

Another recommended measure would be a "margin of sufficiency": the

removal rate minus the rate of fire development. It, too, would be

measured as a linear progression from the point of ignition. This variation of Caravaty and Haviland’s (1967) treatment of critical times and

reaction times would provide a measure of evacuation system performance

at the patient/fire interface. When the margin of sufficiency equals

zero, evacuation is proceeding at the same pace as the fire and the

effort is just barely sufficient to avoid additional casualties. When it

is negative, the effects of the fire are spreading faster than patients

are being evacuated and further death or injury would be expected to

result. When the margin of sufficiency is positive, the removal rate

30
exceeds the rate of fire development. The widening margin at the

patient/fire interface permits other activities, like firefighting,

to occur without interfering with the evacuation effort.

In conclusion, the adoption of the proposed measures cannot be fully

supported by the currently available data. Nevertheless, they illustrate

the types of measures that have to be developed if the special problems

of non-ambulatory evacuees are to be studied and solved. System performance measures will require evacuation system models that can be tested

against performance in actual emergency evacuations.
4 GUIDELINES FOR THE DESIGN AND ASSESSMENT OF EVACUATION SYSTEMS

The systematic analysis of the evacuation process is ultimately a matter

of measurement of initial conditions and of performance. Measures of

initial conditions such as patient mobility and the physical layout of

the facility must be supplemented with measures of predictable changes

in initial conditions as the fire presents new obstacles to or reduced

opportunities for efficient performance. Measures of performance would

include how assistants can be expected to carry out evacuation tasks

during a fire. The best approximations of these initial conditions and

performance factors that can be supported by the available evidence

appear below as guidelines for the design and assessment of evacuation

systems. Recommendations for additional research on the patient, staff,

and building factors in the evacuation process are in Chapter 5.

4.1 DESIGN CONDITIONS

Although the circumstances involved in the origin, progress and outcome

of a particular fire generally can be reconstructed with some accuracy,

it is quite difficult to predict these circumstances. Yet predicting

the nature of a future fire is a prerequisite for planning emergency

training programs or drills, for designing an adequate fire evacuation

system, or for certifying the reliability of either. That is, a model

of a typical emergency situation must provide performance requirements

for evaluating the design of an evacuation system, including critical

initial conditions imposed by the fire and the ideal performance conditions of an evacuation team.

The idealized set of emergency conditions provided by the model to

evaluate the performance of an evacuation system should help determine

the best results that can be expected if every component of the evacuation system functions properly. In the case of hospital, nursing home

or rooming house fires, however, little systematic data is available

to pinpoint these performance requirements. However, based on Lerup's

(1975) analysis of ten nursing home fires and other reports (Caravaty

and Haviland, 1967; Ferguson, 1975; Lefer, 1976), the following design

conditions are reasonable first approximations.

4.1.1 Critical Initial Conditions

Critical initial conditions are the typical or likely state of the

patients, building and staff at the time the decision to evacuate is

made. Both the mobility status of the patients and the physical layout

of the building are facility-specific initial conditions. This means

that patient mobility is a function of the facility's specific custodial

or therapeutic mission and the effective range of wheelchairs or rolling

beds is a function of maneuverability restrictions imposed by specific

32
corners

initial

door jambs

conditions

, and building design features. Seven examples

that are more generally applicable follow.

of

4 . 1 . 1.1

The degree of exposure to risk of ambulatory and non- ambulatory

occupants of a building during a fire is a function of their initial

proximity to and their remaining near the fire or its negative effects

rather than of their mobility or dependency status.

4 . 1 . 1 .2

The maximally dependent patients may either be (a) randomly distributed

throughout the sleeping, treatment, and circulation areas of the facility

or (b) concentrated in a relatively compact treatment, dining, or assem- bly area of the facility. These are the two most extreme cases. The

randomly distributed condition, (a), would be typical both of therapeutic

and custodial situations throughout the day and of late evening and

overnight periods when most patients would be asleep in their rooms. This condition places great emphasis on travel time and exposure during

the supply and removal phases. The concentrated condition, (b), would be

typical of specialized intensive care facilities and of dining or worship

periods in a more diversified unit. This condition, (b), places the

greatest effort on the availability of preparation manpower and congestion or queuing. Both conditions must be considered in the design *nd

evaluation of an evacuation system.

4 . 1 . 1.

3

It is assumed that there will be few staff assistants within a threatened

zone initially, but their numbers will increase over time. The concern,

here, is the actual (in contrast to assigned) number of assistants present. The rate of increase in the manpower supply is largely facilityspecific and depends on the staffing of adjacent zones within the

facility, the location of the facility with respect to other facilities,

such as fire departments, and the nature of the road system that connects

the threatened facility with other facilities.

4 . 1 . 1.4

The available staff is likely to be concentrated near the nursing station

or other center of operations like a pharmacy or laboratory. Even

granting this assumption, the design of an evacuation system should be

based on initial travel distances that are equal to or greater than the

distance from the nursing station to the point of origin of the fire.

An initial condition can be generally applicable and still have its

specific form of application determined by the facility or patient

population to which it is being applied.

33

5
4. 1.1.

5

The origin of the fire may be (a) near the most distant patient bed from

the nursing station or (b) at the location of a known fire hazard. In

the distant condition, (a), a gradually developing fire of accidental or incendiary origin is more likely to grow out of control in a location

that is removed from frequent staff surveillance from the nursing station. These fires force consideration of issues of travel time, fire

development on more than one front, and blocked access to patients and/or

exits. This would be a typical location for a fire late at night. The

known hazard condition, (b), includes laundry and trash chutes; open

flames used in kitchens or laboratories, volatile substances used in

treatment rooms or operating theaters and poorly ventilated electrical

or thermal equipment as in data processing or mechanical equipment areas. Such fires are likely to occur much closer to the center of a health care facility and to develop more rapidly than fires originating in patient

areas. Fires toward the center of the facility are likely to be detected

because they are likely to be in areas where there is staff surveillance.

If undetected, however, then because of their location and rapid growth,

these fires can grow into major fire emergencies. Such fires force con- sideration of issues like asphyxiation of staff assistants, blocked

egress routes, and major congestion and queuing problems.

4.1 .1 .6

Although the details of fire growth are beyond the scope of this report,

it is essential that any evacuation or protection plan must be predicated

on increasing levels of stress and diminishing options for escape as time

passes. ( f

4.1 .1 .7

A critical portion of the evacuation process will have to be accomplished

within the first few minutes after the decision to evacuate has been made

because visibility will decrease rapidly with the growth of a fire.

Although this is related to Section 4. 1.1.6, it is being considered

separately because vision plays a central role in direction finding,

task performance, and decisionmaking under highly uncertain conditions.

Put differently, the opportunities for efficient task performance will

decrease as the fire progresses and visibility decreases.

4.1.2 Ideal Performance Conditions

The ideal performance conditions can be facility-general or facilityspecific. In either case, the concern is with the most effective use

of manpower and equipment in an actual fire emergency evacuation. Staff

size and staff capability are facility-specific. For example, more

assistants with a higher level of professional training would be expected

to be on duty in the intensive-care unit of a general hospital than in a custodial nursing home. For either type of facility, however, staff

preparation for conducting a fire ^ipergency evacuation will be a function
of the specific facility's administrative policies. Seven examples of

performance conditions that can be assumed to be generally applicable

to hospital or nursing home emergencies follow.

4. 1.2.1

Total evacuation of the threatened zone will be required. Any evaluation of an evacuation performance must consider the removal of all

dependent patients from a threatened zone as a minimal objective.

4. 1.2.

2

Dependent patients will be assisted in the order of their exposure to

the threats of flame, smoke, heat, or toxic fumes. During the earliest

and most critical portions of the evacuation process, the sequential

servicing of "next most threatened patients" appears to be essential

to the success of the total effort. At later stages, when the immediacy

of the threat diminishes or the degrees of exposure of the unserviced

dependent patients approach equality, the order in which the remaining

patients are serviced will probably have less bearing upon the final

outcome.

4. 1.2.

3

Movement speeds during the evacuation process will either be at a fast

walk or at a slow walk. The fast walk condition would be typical of

assistants (including firemen) as they first respond to the emergency

during the manpower supply phase and as they move from one patient to

another during the manpower resupply phase. It also applies to fully

ambulatory patients escaping without assistance. A speed of approximately 7.00 f.p.s. (2.18 m.p.s) is the maximum that can be assumed for

level walking under these conditions. This speed is based on the assumption that there is no intervening activity like closing doors to patient

rooms (Murray, 1966). If intervening activity is considered, the slow

walk condition would apply. Adapting Fruin's (1971) 3:1 ratio between

horizontal speeds on the level and on stairs, the horizontal component

of a fast walk down stairs would be approximately 2.33 f.p.s. (0.70

m.p.s.). The rates for ascent would be approximately 35 percent slower.

It is assumed that people will not run at any point in the evacuation

process.

The slow walk condition would be typical for unassisted elderly or handicapped evacuees, all assisted patients and their accompanying

assistant(s) during the patient removal phase, and all assistants engaged

in moving equipment, searching for victims or providing intermediate

protection by closing doors.

From unpublished preliminary data on the movement speeds of unassisted

elderly and handicapped person using various prosthetic devices

(E. Steinfeld, personal communication, 1976; J. Templer, personal

communication, 1976), it appears that a movement speed in the range

of 2.50 f.p.s. (0.75 m.p.s.) would be a reasonable assumption for slow
walking on an unobstructed level route. In general, the group that

moves the slowest are persons who use prosthetic walkers. However

Steinfeld reports one wheelchair user who moved at 0.56 f.p.s. (0.17

m.p.s.) and others who were only slightly faster. These people would

require assistance. In the absence of relevant data, it is assumed that

assisted evacuees would progress at approximately the same speed. Similarly, accepting Fruin's 3:1 ratio, the horizontal component of the

slow walk down stairs would be approximately 0.83 f.p.s. (0.25 m.p.s)

with ascent slightly slower. All of these rates of movement (fast versus slow and level versus stair) are substantially in accord with

the unpublished preliminary results of a simulated evacuation conducted

by the Fire Research Station in England (Appleton and Quiggin, 1976).

In addition, Jin (1976), Watanabe, Nayucki, and Torizaki (1973) and

Tashida (1975) have shown that movement speeds are further reduced in

proportion to the density of smoke.

4. 1.2.

4

All dependent patients within the threatened zone will require some preparation assistance. While some patients will be less dependent than

others, it should be assumed that all will need at least to be awakened

or reoriented toward the nearest exit. In critical situations, preparation can involve, for example, switching the patient from a fixed to

a portable life support system or transferring the patient from a bed

to a stretcher. The time involved in preparation is critical to the success of the overall evacuation effort.

According to unpublished preliminary data, the mean and modal amount of

time required for relatively extensive preparation during a simulated

evacuation was 120 man-seconds (I. Appleton, personal communication,

1976). Recognizing that patients may require considerably more or less

preparation than was called for in that simulation, and with no other

data available, 120 man-seconds will be taken as a resonable approximation of the time which should be allowed for preparation.

4. 1.2. 5

‘ 1

Dependent patients will be fairly cooperative with assistants during the

preparation and removal phases of the evacuation process. Seemingly

counterproductive patient behavior that has been reported can be

attributed to the highly unfamiliar and uncertain circumstances of fire

emergencies

.

4. 1.2.

6

Assuming a relatively high level of professional commitment to the wellbeing of their charges, trained assistants will perform preparation and

removal tasks to their endurance limits. Their efficiency of task performance can diminish over time due to physical and mental fatigue alone

or because their exposure to flame, smoke, toxic fumes or heat exceeds

their tolerance level. The major exceptions should occur when an assistant is unfamiliar with his environment and unaccustomed to his

36
role or is professionally uncommitted and feels no sense of obligation.

The former case must be considered in light of Haber's (1977) findings

of annual staff turnover rates in excess of 50 percent in nursing homes.

The latter case could apply to visitors or spectators off the street who

find themselves pressed into service.

Trained assistants generally will make correct decisions based on available information during the evacuation process. This assumption, like

patient cooperation and efficient task performance, will not always be

the case. Bickman (1977), for example, reports that assistants often

tend to select egress routes which are more familiar rather than those

which may be more direct. Nevertheless, the assumption of correct decisions which could provide an acceptable level of life safety in a critical fire emergency, like the assumption of well maintained facility with

properly functioning equipment, should be part of one's evacuation system

design.

In sum , given these fourteen general assumptions and the patient, building and staff characteristics of a given facility, it should be possible

to make preliminary estimates of the time that would be required to

perform a successful evacuation of dependent patients in an actual fire

emergency if everything goes well. It also should be possible to estimate the effects of difficulties attributable to patients, building, and

staff characteristics.
5. RECOMMENDED RESEARCH ON EVACUATION SYSTEMS: AN AGENDA

The review of critical intitial conditions and ideal performance conditions, in Chapter 4, demonstrates how little is currently known about

the movement of non-ambulatory hospital and nursing home patients under

emergency conditions. The assumptions in Chapter 4, at best, provide

a very rough approximation of the conditions surrounding a likely emergency evacuation. They fall far short of the detailed understanding

that is required to design or evaluate evacuation systems for the elderly

and handicapped in a systematic manner.

There are at least two broad areas in which a concerted research effort

is necessary in order to provide a basis for reliable design and policy

decisions. One is research on spatial and mobility aspects of routine

health care activities, that is, on initial conditions prevailing when

a fire is discovered or a decision to evacuate is made. The other is

research on actual performance levels under real emergency conditions

in hospitals and nursing homes. A third, more narrowly defined, area also requiring research is intermediate protection and evacuation tradeoffs. Specific research topics for these three areas are discussed in

Sections 5.1, 5.2, and 5.3, respectively.

5.1 INITIAL CONDITION MEASURES

This section focuses on quantifiable descriptors of the normal states of

the patients, staff and building at key points throughout the daily

routine. In order to develop a basis for determining the spatio-temporal

relationships between potential fire victims and potential assistants,

as those relationships are defined by the physical layout of the building

and the location of the fire, further research is needed. Since these

relationships will vary according to the nature of ongoing activities,

specific attention must be paid to developing a framework that can accom- modate the distinctions between a situation that might occur at night

when all of the patients are asleep and one that might occur at noon when all are assembled with friends, visitors, and volunteers for lunch

and relaxation. Only those research issues that bear directly upon the

evacuation of non-ambulatory patients from health care facilities are included.

5.1.1 Mapping of Staff and Patient Routines Throughout the Daily Cycle

This issue refers to a spatio-temporal mapping of the characteristic

patient, staff, and visitor activities throughout the day and night.

A person's location is related to his or her ongoing activity. The

distances between dependent patients and staff assistants are a function

of their respective locations. The time required for the latter to come

to the aide of the former is related to these distances. Therefore, it

is essential to know who tends to do what, where, when, and with or for

whom if accurate assumptions about patient demands and manpower availability are to enter into evacuation system design or assessment.

Although not directed to evacuation, there are a substantial number of

38
behavior mapping studies in health care facilities (Gump and James,

1970; Ittleson, Rivlin and Proshansky, 1970; LeCompte and Willems, 1970;

Lippert, 1971 a,b,c; Srivastava and Good, 1968; Trites, et al. , 1970).

One study strongly indicated that the least competent nursing home

patients tend to be assigned to rooms that are the farthest from the

nursing station (Bader, Maxwell and Watson, 1972). Bader et al.’s findings have been confirmed by Haber (1977).

5.1.2 Modeling of the Spatial Organization of Health Care Facilities

This issue refers to a quantitative description of spatial relationships

and communication networks between specifiable activity areas. Given

the diversity of health care facility floor plans, a conceptual language

is needed to describe the spatial organization of a building. This would

be in contrast to the use of descriptors rooted in historical styles

(Kirkbride, Nightingale, pavilion, etc.) or of symbolic labels (Y-shaped,

high rise, noninstitutional , etc.). Without such a conceptual language,

virtually all design and regulatory decisions dealing with occupant

behavior in fire emergencies will be building-specific.

Also, what is needed is an objective format for incorporating alternate

route structures, corridor loadings, channel widths, intervening opportunities and other attributes of connectedness, redundancy, extent and

capacity into the description of a health care facility. A geometric

typology of hospital layouts developed by Wehrli and Kapsch (1972)

represents a preliminary step in this direction. To date, buildi ig-scale

adaptations of location theory and diffusion models developed in economic

geography and industrial engineering are few in number (Archea, 1974;

Baer, 1974), but show some promise.

5.1.3 Studies of the Accessibility of Egress Routes

This issue refers to measures of the difficulties introduced by configurational obstacles along an exit route to the movement of special

equipment and the handicapped. Research on the mobility of the elderly,

people using wheelchairs and other prosthetic devices, and persons with

acute motor disabilities (e.g., hemiplegia) is the basis for the latest

revision of the ANSI A117.1 "Specifications for Making Buildings and

Facilities Accessible to and Usable by Physically Handicapped People"

(Steinfeld, 1977). Preliminary research has been initiated on bearing

stretchers down stairs, through doors, and around tight corners by

Johnson and Jones (1977).

To fully understand how to evacuate non-ambulatory hospital or nursing

home patients, specific studies of architectural barriers and equipment

along an exit route, and their consequences for unobstructed passage,

are necessary. Other issues like excessively high or low coefficients

of friction on walking surfaces and the heights of thresholds along

the egress route also should be considered.

39
5.1.4 Recording the Points of Origin of Health Care Facility Fires

This issue refers to a systematic mapping of the points of origin of

actual fires to establish where ignition is most likely to occur and

where it is most likely to result in a fire that is serious enough to

require evacuation. The topic is important because objective evacuation

system design and evaluation, in large part, will be determined by an analysis of performance for the most critical conditions in which a fire is likely to occur.

Although the point of origin is almost always noted (e.g., Lefer, 1976;

Lerup, 1975), it is only beginning to be the object of systematic analysis. Post-incident investigations by Haber (G. M. Haber, personal com- munication, 1976) have indicated that a high percentage of nursing home

fires originate in rooms that are the farthest removed from the location

of the nursing station. In conjunction with the British Columbia

Department of Health and the National Research Council in Ottawa,

J. E. Breeze and R. S. Ferguson have moved to establish a fire incident

reporting system for extended care facilities which will include this

kind of spatial data.

5.1.5 Field Observations of Emergency Training Procedures and Drills

This issue refers to a documentation of actual levels of staff participation and performance in in-service fire evacuation programs. This

topic will supply baseline data for evaluating a staff assistant's

performance during an actual fire emergency.

The work of Dynes and Quarantelli (1968), on changes in the structure of

previously arranged work groups in the face of an actual emergency, provides one framework for conceptualizing this problem. Of particular

interest are who does and who does not participate in the program, the

amount of instruction versus supervised practice and certification, and

the manner in which the characteristics of the emergency are simulated.

Haber (1977) indicates that an annual staff turnover rate in excess

of 50 percent tends to negate the benefit of much of the staff training

for emergency evacuation in nursing homes. Similar studies have been

initiated by John P, Keating and Elizabeth F. Loftus of the Department

of Psychology, University of Washington. Controlled exposure to actual

fire and smoke during training sessions involving the nursing, engineering, housekeeping, laboratory, clerical, and other personnel of one hospital is reported by Simon (1977).

5.1.6 Determination of Critical Design Conditions

This issue refers to the facility-specific determination of the most

demanding evacuation effort that would be likely to occur. If the

spatial behavior of patients and trained staff could be mapped on a working model of the unobstructed linkages between work stations,

threatened patients, and safe exits, then one can predict which fire

situations would be the most critical in terms of travel times per

assistant, queue formation, fire growth rate, and special equipment

40
needs. This would provide an improved basis for planning realistic

staff training programs and for weighing the performance trade-offs

between evacuation and detection, protection, and suppression systems

for a particular health care facility. Caravaty and Haviland s (1967)

work on the placement of exits includes a preliminary assessment of

this problem.

5.2 PERFORMANCE MEASURES

This issue refers to statistically stable estimates of the levels of

performance for required tasks during an emergency evacuation. Of

specific concern is the rate at which each task can he performed under

stress and the resultant cost in time or manpower lost due to energy

expenditure, exposure to stress, or counterproductive allocations of

effort. Since the level of performance will depend in part on each

assistant's understanding of the urgency of the fire situation, attention

must be given to the cues used by the patients and staff to govern their

own actions during an evacuation effort. Only those research issues that

bear directly on the establishment of performance criteria for trained

staff assistants are listed.

5.2.1 Determination of Manpower Supply and Resupply Rates

This issue refers to measures of the elapsed time between the decision

to evacuate and the arrival of the first assistant(s) at the side of

the most threatened patients(s) and the intervals at which successive

assistants arrive at the sides of the next most threatened patients

under simulated fire emergency conditions. This includes the time that

it takes the signal to evacuate to reach the available assistant(s),

the termination of the assistant(s) ongoing activity, the rate at which

they move toward the most threatened patient(s), the time lost to perform intervening tasks enroute (like calling the fire department or closing doors to patient rooms), the act of locating the most threatened

patient(s) under low visibility condition^, And the time it takes for

the assistant to get into a position where preparation can begin. Variations in the duration of these sub-tasks relate to changes in levels of

information and of stress as the fire and the evacuation continues. The

application of this research will require standardized models of typical

architectural layouts, of typical hospital and nursing home fires, and

of typical staffing practices. Lerup (1975) has described some of the

factors involved in initial response times. Very little research has

been done on the supply of assistants during a building evacuation.

With regard to the impact of the fire and its effects on movement speeds

and direction findings, however, the research by Edmondo and Macey (1968)

and Garner and Lowrey (1976) on the effects of lighting and signage on visibility through smoke is of value. In addition, considerable research

on the effects of reduced visibility on walking speeds in smoke-filled

corridors is being done by the Fire Research Institute of Japan

(Watanabe, et al., 1973; Jin, 1976).

41
5.2.2 Studies of Alternative Preparation Procedures Under Stress

This issue refers to measures of the rate and efficiency with which a succession of patients can be prepared for removal under simulated fire

emergency conditions. Variables to be considered include the degree of

patient dependency (prosthetic and life-support requirements), the type

of special equipment to be used, and the specific procedures followed

by the assistant(s) . Given a range of patient dependencies, research

could stress the development of new equipment and techniques.

The most extensive research on patient preparation has been the fire

evacuation exercise conducted by the Fire Research Station at Hackney

Hospital in London (Appleton and Quiggin, 1976). That simulation used

a special bedsheet which could be wrapped around a sleeping patient

and used as a litter. Einhorn (1975) also has addressed the decline

in task performance introduced by exposure to smoke, toxic fumes and

heat.

5.2.3 Studies of the Movement Capabilities of the Elderly and

Handicapped

This issue refers to measures of the maximum speed and continuity of

movement on the part of patients in various mobility categories under

simulated fire conditions (fire drills). In addition to speed, other

important factors include; spatial requirements and maneuverability

limitations imposed by the type(s) of prosthetic devices used; comparison between the speed, flexibility, and spatial requirements of moving

with or without an assistant; and the direct effects of the fire on

a debilitated patient's ability to maintain a steady course toward an

exit. The results of such research could help determine which class

of victims should or should not be assisted all the way to an exit.

Preliminary data on how fast users of various prosthetic devices can move on level surfaces in non-emergency situations has been collected

by Edward Steinfeld, at the State University of New York at Buffalo,

and John Templer, at the Georgia Institute of Technology. The effects

of glare and other sensory factors on the routine movement capabilities

of the elderly have been studied by a number of researchers (e.g.,

Pastalan, Mautz and Merrill, 1973). There appears to be no research

on the movement of patient-assistant pairs. None of the cited research

has considered movement in emergency situations, nor has the research

on the effects of smoke density on walking speeds addressed the special

problems of a dependent, non-ambulatory population.

5.2.4 Studies of Alternate Removal Procedures Under Stress

This issue refers to measures of the overall efficiency and effectiveness

of various techniques and strategies for removing dependent patients from

a threatened zone. There are two separate but related issues; (a) the

actual techniques or procedures used to move patients (fireman's carry,

wrap in a sheet and drag, pile several patients onto a rolling bed,

etc.) and (b) the staging of the removal effort, by increments, from the
point of preparation to the safe zone. However, the manner in which the

patient is transported may affect how far he or she can be transported

efficiently and at what cost in terns of fatigue and energy expenditure.

Therefore, these two issues are considered together.

In the development and evaluation of patient transport techniques and

equipment, factors to be considered include: the rate of movement and

other time-based criteria, the amount of energy expended by each assistant, the manpower required per patient, and the evacuee's exposure to

risks associated with removal (as opposed to risks associated with the

fire itself). In assessing removal by increments (e.g« , intermediate

protection), changes in manpower availability over the course of the

fire, the physical characteristics and condition of the exit route,

and the effectiveness of the evacuation process in terms of lives saved

and injuries avoided should be addressed.

The only systematic study of the removal process to date has been the

timing of the simulated evacuation at the Hackney Hospital by Appleton

and Quiggin (1976). Since each assistant was free to choose his or her

own technique (except for the special sheets) and strategy, its results

are of limited applicability. Moreover, the benefits of research on specific removal strategies, transport methods, and their interaction,

will not be realized until explicit models of architectural layouts,

fire development, and staffing practices for hospitals and nursing homes

become widely available.

5.2.5 Studies of the Use of Information in High-Risk Decisionmaking

and in Route Selection Under Stress

This issue refers to (a) measures of the impact of training and of the

effects of the fire on an assistant's use of visual and other sensory

cues to assess the prevailing level of risk and (b) to the assistant's

selection of an appropriate course of action under simulated emergency

conditions. An actual fire presents most people with a very unique

context for decisionmaking. Ambiguities can be created by alterations

in the cues which an assistant normally uses to orient himself or to

gauge the current state of affairs, and by discrepancies between an assistant’s experience in an actual fire and the expectations he gained

in a training program. The consequences can be inappropriate decisions

with potentially lethal implications.

Since cues are more directly amenable to control than the decisions that

follow from them, it is the effectiveness of specific cues that is at

issue, rather than the consequence of a specific class of decisions.

The central concern, then, is how certain cues elicit certain behaviors

(decisions) under various circumstances. Best's (1970) studies of

direction finding in buildings under nonemergency conditions, Lerup's

(1975) reconstruction of the decisions made by the staff in ten nursing

home fires, and the theoretical formulations of Breaux, Canter and Sime

(1976) and Canter and Matthews (1976) are among the few efforts in this

direction. New research by Bickman (1977) on the effects of prior experience and familiarity on the selection of emergency egress routes

43
and work of Tad Ogrodnik and Robert Beck for the Canadian Department

of Health and Welfare on patterns of stair use for interfloor travel

in high rise office buildings may shed new light on the process of

route selection under stress.

5.2.6 Studies of the Effects of Overmanning on the Evacuation Process

This issue refers to tests of the inverse, perhaps U-shaped, relationship

between the number of assistants involved in the evacuation effort and

the total evacuation time. In the Appleton and Quiggin (1976) simulation, the total time required to evacuate 30 bed-ridden "patients"

actually increased as the number of staff assistants increased. This

suggests that after a certain point, having even more helpers may

actually reduce overall effectiveness. Reports of several nursing home

fires indicate that administrators and other supervisory staff members

who have not previously participated in drills or training programs

frequently take charge of an evacuation effort in an actual emergency.

As a result, they often diminish the effectiveness of those more fully

trained. Therefore, research on the impact of the number, status and

experience of assistants on the duration and effectiveness of evacu- ation activities is needed if improved procedures are to be developed.

Although this specific problem has received only anecdotal treatment in

the evacuation literature, the theoretical basis for investigating

"overmanning" (Barker and Gump, 1964) is well established.

5.2.7 Simulations of Total Evacuation System Effectiveness

This issue refers to analogs of the relationships between patient mobility status, facility layout, fire development, staff performance and

total evacuation time and the cost in terms of lives lost or injuries

sustained. When the parameters of the evacuation process are sufficiently understood, simulation techniques can be used to determine optimum

performance criteria for either a standardized or specific health care facility. This capability would enable planners, regulators or evaluators of evacuation systems to establish the risks and benefits of a range of options regarding the provision and operation of evacuation

systems for non-ambulatory hospital and nursing home residents. It also

would be of value in evaluating trade-offs between evacuation, detection,

supression, and protection systems in health care facilities.

There are simulations of the hydraulic model of evacuation in health care facilities. These include Henderson's (1971) use of a gas diffusion

model to simulate crowd flow in nonemergency situations and Cathey’s

(1974) analysis of "evacuation trees." The most elaborate simulations of

human behavior in building fires are by Stahl (1976) and by John Breaux

at the University of Surrey. However, these do not currently address

non-ambulatory building occupants.

5.2.8 Calculation of Optimal Evacuation and Training Procedures

This issue refers to the facility-specific determination of the most

effective evacuation techniques and strategies, given a known patient

44
population, physical plant, and staff capability or other local conditions. When response times, preparation times, removal rates, and

decisionmaking can be mapped on the physical layout of the facility

and the daily routines of patients and staff, an evacuation plan can

be tailored to the needs of a specific facility. This capability would

help structure drills and training programs so as to maxmimize the correspondence between the staff assistant’s expectations and the actualities

of the most likely fires.

5.3 INTERMEDIATE PROTECTION AND EVACUATION TRADE-OFFS

This section addresses the assessment of the risks and benefits of

protecting non-ambulatory patients in place versus evacuating them to

a zone of safety inside or outside the building during a fire. Since

most victims of fires in health care facilities die of the indirect

effects of the fire (smoke, toxic fumes or heat) rather than from the

fire itself. Since most of these fires are relatively minor in terms

of the area of involvement or the time to extinguishment, it has become

more common to think of fire protection in hospitals and nursing homes

in terms of closing the doors to the patient's rooms than in terms

of total evacuation. It is assumed persons behind closed doors would

be able to "ride out" the fire until it is extinguished. For example,

Lefer (1976) reports four people who were unaware of a very serious

fire in an adjacent room and survived because the door was closed. By

contrast, there also are reports of people who waited behind a closed

door until they just couldn't stand it any more and were found near- death from smoke inhalation in the corridor outside their rooms (Lerup,

1975; B. Levin, personal communication, 1976). These reports indicate

that a person may not voluntarily ride out a serious fire if its toxic

and thermal effects are believed to be accumulating on the other side

of the door that is the only means of escape. Several research issues

that are related to this trade-off will be discussed.

5.3.1 Studies of Occupants' Confidence in the Fire Safety of an Intermediate Protection System During a Fire

This issue refers to measures of the effects of stress and uncertainty

over relatively short periods of time on a person's willingness to

remain in a protected area near the origin of a spreading fire. The

issue is not how long a wall or door can resist fire and smoke, but

how long a person will accept that protection as the sole means of his

or her survival. Since perceptions of time are altered in stressful or high-risk situations, this perception and its effect on subsequent

behavior can be quite critical.

The main concern is to understand the impact of time and of information

about the fire or about attempts to contain it on a person's decision

either to rely on the performance of an intermediate protection system

(door or wall) despite the immediacy of a growing threat or to attempt

to escape via a route that may be increasingly filled with the lethal

effects of a fire. This is a precarious situation. It is possible

that a person's confidence in available protection will diminish just
as the need for that protection increases and as the only alternative,

escape, becomes less and less viable. Unless the fire is extinguished

rapidly, time would appear to work against anyone who is aware of the

proximity of their refuge zone to the fire or its direct effects. Thus,

to determine when and where the use of closed doors will provide adequate

protection and how to inform occupants about the risks associated with

riding out versus fleeing a fire, a systematic study of occupants'

perception of protection in a fire emergency is needed.

5.3.2 The Impact of Closing and Closed Doors on Initial Response Time

This issue refers to measures of the extra time required to close doors

and to locate victims behind closed doors while responding to the most

threatened patient(s). There are two related aspects of this problem:

(a) how much closing doors to patients 5 rooms while enroute to the

most threatened patient increases the time of the intitial response,

hence, the risk to that patient and (b) how much closed doors delay

finding the most threatened patient(s). The first aspect is relatively

straightforward. The second, however, is not because the assistant and

the occupants behind closed doors both are uncertain about what is happening on the other side of the door. In order to reduce that uncertainty,

each door without an unobstructed vision panel must be opened. This can expose the assistant and the occupant to the effects of the fire, and it can delay the assistant from reaching the most threatened occupant.

Additional time can be lost be opening and closing the doors to empty

rooms, including doors opened and closed by earlier searchers. This

suggests that there must be a standardized approach to and a shared

understanding of a door's position (e.g. , "open" means no one is in here

or this room has already been searched). The effects of a particular

approach to door position on an assistant's delay in responding to a most threatened patient should be studied.

Research on the time needed to close doors and to locate concealed occupants under simulated fire emergency conditions is urged. The British

Columbia Department of Health's fire incident reporting system indicates

that fires may be less readily detected and more likely to grow out of

control if they begin in a room to which the door is initially closed

rather than open (R. S. Ferguson, personal communication, 1976). This

suggests that the flow of critical information may be obstructed when

doors to patient's rooms are closed, resulting in a critical loss of

time in detecting a fire or in deciding to evacuate patients. Archea's

(1974) model of visual access and exposure provides a tentative framework

for considering portions of this problem.

5.3.3 Simulations of Protection Versus Evacuation Options

This issue refers to analogs of the relationships between the temporal

requirements of an evacuation procedure and the temporal costs of providing intermediate protection, measured against various manpower and life

saving criteria. Once patient confidence and staff efficiency issues

associated with using intermediate protection in hospital or nursing

46
home fires are fully explicated, simulation techniques can be used to

determine the applicability of these two options for different patient

populations, building arrangements, or staffing conditions* For the

most part, these simulations will probably be most useful as subroutines

within the much larger simulations of the overall evacuation system (see

Section 5.2.7).

In sum , once data become available for most of the research issues

discussed in this chapter, it should be possible to (a) make fairly precise estimates of the total evacuation time for non-ambulatory patients

in typical or specific facilities; (b) develop more appropriate staff

training procedures in general or in response to special circumstances;

(c) determine the risk-benefit trade-offs between evacuation systems and

detection, protection, or supression systems in typical or specific

cases; and (d) promulgate more realistic regulations affecting the design

and management of systems for evacuating non-ambulatory patients from new or existing health care facilities.

Much of this increased capability for predicting performance in emergency

evacuations would result from a more complete understanding of the

effects of building factors on patient and staff behavior. Thus, it

should be possible to use this research to improve the physical design

of hospitals and nursing homes from a life safety viewpoint. It also

should be possible to weigh the architectural implications and costs

of increased fire safety against other attributes (e.g., accidents,

crime) and the operating requirements of the facility (e.g. keepi ig

the doors to patient rooms open or closed at night).

This research agenda can and should be put into a larger context because

the proportion of the population represented by the elderly, handicapped

or otherwise non-ambulatory patients in hospitals and nursing homes is

relatively small (see Wooliscroft, 1975). The research effort, and any

design or policy initiatives that might follow from it, could be of

potential benefit to the much larger population of people who have

limited capabilities for getting themselves out of a burning building.

This larger population includes people who are asleep (the entire population, roughly one third of the time), those who are intoxicated or under

the influence of debilitating drugs or medication, persons suffering

from temporary illness or injury, infants and young children, and anyone

else who is actually entrapped in a portion of a burning building. It

also includes the elderly and handicapped in buildings other than health

care facilities — like private homes, half-way houses, department

stores, recreational facilities, and places of employment (an increasing

opportunity for the handicapped since the enactment of the "Rehabilitation Act of 1973" [P.L. 93-112]). Finally, it includes the indigent

occupants of rooming houses and other forms of transient lodging --

a most vulnerable population in very high-risk settings. By considering

this larger population of people and of building types, the effective

targets of the proposed framework and recommended research program begins

to encompass a significant proportion of all people and situations from

which the fatalities and injuries in building fires are drawn.

47
6 . SUMMARY AND CONCLUSIONS

The predicament of the non-ambulatory and dependent patient in a health

care facility or nursing home who needs to be removed to safety during

a fire emergency is addressed.. The hydraulic model, predicated on ambulatory, nondependent building occupants, and with its stress on the safe

end—the exits—of the emergency evacuation route, is found wanting. An

alternative approach is proposed. This approach focuses on the threatened end-—the end near the fire—and on the dependent and non-ambulatory

patients in the vicinity of the fire.

Chapter 1 addresses the problems the non-ambulatory patient who needs

assistance from others during a fire emergency if he or she is to be

evacuated without serious injury or loss of life. The chapter also considers the contingent problems that the assistants or helpers, such as the facility's staff or outsiders, including firefighters, face during

a fire evacuation. It is the assistants' task to prepare and remove the

patients to a safe refuge, starting with the most threatened patients.

Removal is conceptualized as an incremental process, and the idea of

intermediate refuge is introduced. Using an intermediate refuge is

hypothesized to (1) reduce the demand on the exit channel, (2) maintain

a supply of assistants for other most threatened patients, while, at

the same time, (3) reduce the immediate threat from the fire and its

products to the dependent, non-ambulatory patients in the intermediate

refuge. Incremental removal may prove to be a better use of human

resources and of the facility and may result in fewer lost lives and

serious injuries than removing patients, one at a time, from the

threatened end to the safe end of an evacuation route.

The incremental approach is based on the assumption that the initial

supply of assistants during a fire emergency will be limited but that

additional assistants will become available over time. One implication

of a limited initial supply of assistants is that these assistants will

probably have to help more than one patient. Because of the stress and

effort of providing assistance, the assistant must include a rest-andrecovery period, however brief, as part of the evacuation process.

Efforts by assistants that go beyond their levels of endurance increase

the risks to the health and safety of assistants and, by implication,

to those who the assistants are helping or could have helped (had the

helpers been able to continue with assisting patients).

Based on the description in Chapter 1, Chapter 2 reconceptualizes the

evacuation process into five sequential phases: the manpower supply

phase, the patient preparation phase, the patient removal phase, the

rest and recovery phase, and the manpower resupply phase. For each phase

of the evacuation process, its most critical and the most effective portions are described and the role of building, patient and staff including

staff decision factors are discussed. The purpose of the reconceptualization is to provide a framework for assigning priorities to building,

patient and staff factors that can control the success or failure of the

evacuation process.

48
Chapter 3 addresses the potential relationships among the phases

presented in Chapter 2. The five phases, and the parameters and

measures described in Chapter 3, illustrate the variables which a model

of the evacuation process must include. The system parameters and

measures are (1) the process of fire development, (2) the mobility

status of patients, (3) the locations of persons (patients and staff)

and the physical layout and condition of settings in a facility, which

is called "spatial distribution," (4) task proficiency of assistants,

and (5) system performance measures. Examples of systems performance

measures are "removal rate," or the rate at which dependent patients are removed from a fire zone, and "margin of sufficiency," or the removal

rate minus the rate of fire development.

Chapter 4 discusses the design and assessment of evacuation systems.

Specifically, it is argued that the analysis of the evacuation process

is, ultimately, a matter of measuring initial conditions, such as patient

mobility and the physical layout of a facility, and of measuring system

performance, such as how assistants are expected to carry out evacuation

tasks during an actual fire. Approximations of initial conditions and

performance factors are introduced—in the form of 14 assumptions—as guidelines for the design and assessment of evacuation systems.

The review of critical initial conditions and ideal performance conditions in Chapter 4 suggests that there has been little research on the

movement of non-ambulatory hospital and nursing home patients under

emergency conditions. Chapter 5 proposes a research agenda to develop

needed information. The chapter reviews the available literature and

recommends a number of studies on the evacuation process. Two areas are emphasized for a concerted research effort. They are: actual performance levels under real emergency conditions in hospitals and nursing

homes, and spatial and mobility aspects of routine health care activities. A third, narrower, area also is recommended: intermediate

protection and evacuation trade-offs. The results of this research

could provide the level of understanding required to design and assess evacuation systems for the non-ambulatory and dependent individual and

to formulate policies for fire emergencies involving threatened populations. The chapter also discusses the potential applicability of the

results of the recommended research effort to additional population and

building types.

In conclusion, the major life safety issue in building fires is, by

definition, the problem of all people who cannot begin to move away

from the effects of a fire fast enough to avoid its debilitating or fatal consequences. The measure is not the number of lives sa\ ^d it

is the number lost. If this preliminary analysis of the evacuation

of non-ambulatory hospital or nursing home patients has shown anything,

It is that the most critical portion of the evacuation process for the

non-ambulatory person lies at the "threatened end" of the evacuation

circuit.

Therefore, anyone who seriously intends to reduce the deaths and injuries

resulting from building fires will have to give much more consideration

49
to the fire victim at the threatened end. This is the target toward

which further research ought to be directed, to which new regulations

ought to be addressed, and to which the design and evaluation of

evacuation, protection, and training programs ought to be focused.

50
REFERENCES

Appleton, I. , and Quiggin, P. "Hackney Hospital Fire Precautions

Project FRS Contribution: An Evacuation Model." Operation Research

and Systems Studies Section, Fire Research Station, Building Research

Establishment, Borehamwood, U.K. , 1976.

Archea, J. "Identifying Direct Links Between Behavior and Its Environment: Toward A Predictive Model." In T. 0. Byerts (Ed.), Environmental Research and Aging. Washington, D.C.: Gerontological Society,

1974.

Bader, J. , Maxwell, R. , and Watson, W. "Doomed Status and the Ecology of

Institutions," Paper Presented at the 25th Annual Meeting of Gerontological Society, San Juan, P.R. , December 1972.

Baer, E. "A Simulation Model of Multidirectional Pedestrian Movement

Within Physically Bounded Environments." (Report No. 47). Institute

of Physical Planning, Carnegie-Mellon University, Pittsburgh, 1974.

Barker, R. G. , and Gump, P. V. Big School, Small School . Stanford, CA:

Stanford University Press, 1964.

Best, G. "Direction Findings in Large Buildings." In D. Canter (Ed.),

Architectural Psychology, London, U.K. : R.I.B.A. Publications, Ltd.,

1970.

Bickman, L. Presentation at the Seminar on Behavior in Fires, University

of Surrey, Surrey, U.K. , March 1977.

Breaux, J., Canter, D. , and Sime, J. "Psychological Aspects of Behavior

of People in Fire Situations." Fire Research Unit, University of

Surrey, Surrey, U.K. , 1976.

Bryan, J. L. "Human Behavior in Fire Situations." (Paper Prepared for

the Second Joint Panel Meeting on Fire Safety and Research, Tokyo,

Japan, October 19-23, 1976). College of Engineering, University of

Maryland, College Park, October 1976.

Canter, D. , and Matthews, R. "Behavior in Fires: The Possibilities for

Research." (CP 11/76). Borehamwood, U.K. : Fire Research Station,

Building Research Establishment, 1976.

Caravaty, R. D. , and Haviland, D. S. "Life Safety From Fire: A Guide

for Housing the Elderly." Troy, N.Y. : Center for Architectural

Research, Rensselaer Polytechnic Institute, 1967.

Cathey, B. H. "A Technique for Analyzing Building Evacuation Plans and

Facilities Designs." American Society of Safety Engineers Journal,

1974 (August), 26-28. ~

51
Dynes, R. R., and Quarantelli, E. L. "Group Behavior Under Stress.”

Sociology and Social Research , 1968, 52 (4), 416-429.

Edmondo, P. M. , and Macey, H» To ’’An Investigation of Lighting Directional Markers for Emergency Egress from Ships Compartments. Phase I,

Study: Lighting Investigation." (Report No. 3561). ANNADIV

NAVSHIPRANDCEN, February 1972.

Einhorn, I. N. "Physiological and Toxicological Aspects of Smoke

Produced During the Combustion of Polymeric Materials." In

Proceedings NSF/RANN Conference on Fire Research , Harvard University,

Cambridge, MA. , June 1975.

Ferguson, R. S. "Fire at Extendicare Ottawa, Sunday, 3 August 1975,"

Division of Building Research, National Research Council of Canada,

Ottawa, 8 August 1975. (Memorandum)

Fruin, J. J. Pedestrian Planning and Design. (Chapter 3: "Traffic and

Space Characteristics of Pedestrians.") New York: Metropolitan

Association of Urban Designers and Environmental Planners, Inc.,

1971 .

Garner, J. D. , and Lowrey, D. L. "Exit Sign Comparisons in Clear Air

and Smoke." Unpublished Manuscript. Office of Aviation Medicine,

Federal Aviation Administration, Washington, D.C., December 1976.

Gump, P. , and James, E. V. "Patient Behavior in Wards of Traditional

and of Modern Design." The Environmental Research Foundation,

Topeka, KS , 1970.

Haber, G. M. Presentation at the Seminar on Behavior in Fires,

University of Surrey, Surrey, England, March 1977.

Henderson, L. F. "The Statistics of Crowd Fluids." Nature, 1971, 229,

381 - 383 .

Ittelson, Wo, Rivlin, L. G. and Proshansky, H. M. "The Use of Behavioral

Maps in Environmental Ps3

r chology . ” In H. M. Proshansky, W. H.

Ittelson, and L. G. Rivlin (Eds.), Environment Psychol ogy: Man and

His Physical Setting . New York: Holt, Rinehart and Winston, 1970.

Jin, T. "Visibility Through Fire Smoke (Part 5: Allowable Smoke Density

for Escape From Fire)." Report of the Fire Research Institute of

Japan , 42 , No. 42, September 1976, pp. 12-18.

Johnson, B. , and Jones, B. "Draft Report on the Problems of Patient

Removal in Buildings." Division of Building Research, National

Research Council of Canada, Ottawa, 1977.

52
LeCompte, W. , and Willems, E. "Ecological Analysis of a Hospital:

Location Dependencies in the Behavior of Staff and Patients." In

J. Archea and C. Eastman (Eds.), ERDA Two . Stroudsburg, PA: Dowden,

Hutchinson and Ross, 1970.

Lefer, H. "Where There's Fire There's Smoke." Progressive Architecture , 1976 (September), 58-63.

Lerup, L. "Mapping Behavior: The Case of Fire." (Working Paper No. 5.)

University of California, Berkeley, 1975. Also available as:

Lerup, L. , Greenwood, D. , and Burke, J. S. Mapping of Recurrent

Behavior Patterns in Institutional Building Under Fire: Two Case

Studies of Nursing Facilities . (NBS-GCR-76-73. ) Washington, D.C.,

National Bureau of Standards, July 1976. Available from NTIS as PB257424.

Lippert, S. "Travel as a Function of Nursing Unit Layout." In H. H.

Field, J. A. Hanson, and C. J. Karalis, Hospital Design Evaluation:

An Interdisciplinary Approach (Appendix IV). (Report No. MSRD 73-14,

PSH-HS-00133. ) Boston: New England Medical Center, December 1971.

(a)

Lippert, S. "Travel as a Function of Nursing Unit Layout, with Utility

Stops." In H. H. Field, et al., Hospital Design Evaluation: An Interdisciplinary Approach (Appendix V). Boston: New England Medical

Center, December 1971. (b)

Lippert, S. "Travel in Single Corridor Nursing Units Ranging From 1-84

Beds.” In H. H. Field, et al., Hospital Design Evaluation: An Interdisciplinary Approach (Appendix VI). Boston: New England Medical

Center, December 1971. (c)

Murray, M. "Comparison of Free and Fast Speed Walking Patterns of Normal

Men." American Journal of Physical Medicine , 1966, 45( 1 ) , 8-24.

Pastalan, L. , Mautz, R. K. , II, and Merrill, J. "The Simulation of Age

Related Sensory Losses: A New Approach to the Study of Environmental

Barriers." In F. E. Preiser (Ed.), Environmental Design Research

(Vol. I: Selected Papers) . Stroudsburg, PA: Dowden, Hutchinson ana Ross, 1973.

Pauls, J. L. "Fire Safety and Related Man-Environment Studies." ManEnvironment Systems, 1975, 5(6), 386-394.

Simon, F. J. "Learning to Put Out Hospital Fires." Fire Journal , 1977

(January), pp. 75, 77.

Srivastava, R. , and Good, L. R. "Patterns of Group Interactions in Three

Architecturally Different Psychiatric Treatment Environments." The

Environmental Research Foundation, Topeka, KS, March 1968.

53
Stahl, F. I. "Some Prospects for Simulating Human Behavior in High-Rise

Building Fires: A Pilot Demonstration." In P. Suedfeld, and

J. Russell (Eds.), The Behavioral Basis of Design . Stroudsburg, PA:

Dowden, Hutchinson and Ross, 1976.

Stahl, F. I., and Archea, J. An Assessment of the Technical Literature

on Emergency Egress From Buildings . (NBSIR 77-1313). Washington,

D.C.: National Bureau of Standards, October 1977.

Steinfeld, E. Specifications for Making Buildings and Facilities

Accessible to and Usable by Physically Handicapped People . Proposed

ANSI A117.1 (1977). Syracuse, N.Y.: Syracuse University, 1977.

Tashida, S. "Walking in the Midst of Smoke." Resume of Symposium

Reports, Symposium on the Physical, Psychological and Behavioral

Aspects of Fires, Japan Fire Science Assn., November 1975.

Trites, D. K. , Galbraith, F. D. , Sturdavant, M. , & Leckwart, J. F.

"Influence of Nursing-Unit Design on the Activities and Subjective

Feelings of Nursing Personnel." Environment and Behavior, 1970,

2(3), 303-334.

Watanabe, Y. , Nayuki, K. , and Torizaki, K. "Actions of Firemen in

Smoke." (Report No. 37). Fire Research Institute of Japan, Tokyo,

1973.

Wehrli, R. , and Kapsch, R. Hospital Bedrooms and Nursing Units. A

Systems Approach for Building Technology . (PB 218-975). Springfield,

VA: National Technical Information Service, 1972.

Wood, P. G. "The Behavior of People in Fires." Department of the

Environment and Fire Office's Committee, Joint Fire Research Organization, U.K. , November 1972.

Wooliscroft, M. J. "The Hospital Fire Problem: Towards a Rational

Approach." Doc. Eng. 265, November 1975.

54
Appendix 1. Schematic Diagrams of the Evacuation Process

Chapter 1 contains seven schematic diagrams of the evacuation process.

Each diagram maps factors and their interrelations that are discussed in

Chapter 1. Each of the six sections in chapter 1 has its own schematic

diagram (Figures 1-6). The final diagram, Figure 7, entitled "Summary of

Major Factors," summarizes the interrelations of the factors that appear

in Figures 1-6.

The figures refer to factors by symbols. The symbols are based on first

letters of key words that describe the factors that are represented. A

key to the symbols appears on the next page. In the key, symbols are listed in alphabetical order; the factors to which they apply are described; and the figures in which each symbol appears are listed.

The symbols in a figure first appear in brackets in the section of

Chapter 1 that references the figure.

The figures indicate the position of the factors on a "maximum threatmaximum safety" dimension. The maximum threat-maximum safety dimension

"scale" appears at the bottom of each figure.

Each figure consists of a series of wide-bodied "arrows"; each arrow is

a unit of behavior that takes a period of time to complete and that

involves one or more persons. The nature of the behavior is indicated

by the symbol in the arrow. Each arrow (unit of behavior over tine) has an initial position on the maximum threat-maximum safety dimension (the

"tail" of the arrow), a path of movement on the dimension (the "body" or "shaft" of the arrow) and a final position and direction (the "head"

indicates the final position and the direction the "head" faces indicates the direction).

To illustrate how to read "threat-safety" for a factor, turn to Figure

7 (page 16). The self-evacuating patients, SE, start at the threat end

of the dimension and move toward and reach the safe end. By contrast,

the resupplied manpower, RM, starts at an intermediate position on the

dimension and moves toward the threat end. As for the self-starting

patients, SS, they do not change their position on the dimension. This

is indicated by an arrow that remains in a vertical plane. These

patients start at the threat end and, during their start-up activities,

remain at the threat end.

Thus, each figure presents factors, their interrelations, and specifies

whether the behaviors that are represented move the person(s) toward

threat or toward safety or leave them in an unchanged position on the

maximum threat-maximum safety dimension.

55
Key to Figures 1-7

Appears

in

Symbol Corresponding Factor Figures:

A Ambulatory status of patients after preparation. 3,7

AP Evacuation assistance provided by trained assistants. 3,5

AR Evacuation assistance jrequired or received by non- 3,7

ambulatory patients.

AR^ The partial ^assistance received by non-ambulatory 6,7 evacuees

.

AR^ The continuation of assistance jreceived by non- 6,7

ambulatory evacuees. CA The continuation of assistance given to non-ambulatory 6,7 evacuees.

d A "distant point" at which the assistant is initially 4,7

located

.

i An "intermediate point" to which evacuees are first 6,7

moved

.

IS The ^initial supply of manpower. 4, 5, 6,

7

LS The later supply of manpower. 6,7

MS The total manpower ^upply for the patient population. 5,7

N-A The non-ambulatory status of patients after 3,7

preparation.

PA The partial assistance given to non-ambulatory 6,7 evacuees

.

PP The preparation provided by trained assistants. 2, 4, 6,

7

PR The preparation required or received by dependent 2,7

patients.

R&R The £est and recovery required by assistants to offset 5,6,7

the effects of fire and fatigue.

RM The resupply of manpower. 2,7

s The "safe end" of the evacuation route. 2,7

SE The se If -evacuating action of independent, ambulatory 1,3,7

patients.

SS The ^elf-starting action of independent, ambulatory 1,2,7

patients.

t The "threatened end" of the evacuation route. 2,7

56
NBS-114A (REV. 9-76)

U.S. DEPT. OF COMM.

BIBLIOGRAPHIC DATA

SHEET

1. PUBLICATION OR REPORT NO. NBSIR 79-1906

3. ftetiptfertf’S Accession ’.e,

4. TITLE AND SUBTITLE

The Evacuation of Non-Ambulatory Patients from Hospital

and Nursing Home Fires: A Framework for a Model

5. Publication Date November 1979

7. AUTHOR(S)

John Archea, Author and Stephen Margulis, Editor

8. Performing Organ. Report No.

9. PERFORMING ORGANIZATION NAME AND ADDRESS

NATIONAL BUREAU OF STANDARDS

DEPARTMENT OF COMMERCE

WASHINGTON, DC 20234

11. Contract/Grant No.

12. SPONSORING ORGANIZATION NAME AND COMPLETE ADDRESS fSfreer, City, State, ZIP)

U.S. Department of Health, Education, and Welfare

Public Health Service

Washington, D.C.

13. Type of Report & Period Covered

oosr

'll..’ I I I Ml' !. 15. SUPPLEMENTARY NOTES

I

!

I Document describes a computer program; SF-185, FIPS Software Summary, is attached.

16. ABSTRACT (A 200-word or less factual summary of most signi ficant information. If document includes a signi ficant bibliography or

literature survey, mention it here.) This report is directed toward the problem of evacuating dependent , non-ambulatory

persons from fires in nursing homes and other health care facilities. It deals

only with those behavioral and building factors that bear on the activities that

follow directly from a decision to evacuate patients from a fire zone in a nursing

home or similar facility. The examination is based on the rejection of the model

which is the basis for current life safety regulations because it assumes independent

occupant mobility. This assumption does not apply to dependent, non-ambulatory

persons. The major objective of the report is to identify those factors that must

be considered in order to determine the ideal performance of a hospital or nursing

home evacuation system for non-ambulatory patients when all components or persons

in that system act as they are designed or trained to act. These factors are presented as part of an analysis of evacuation as a five phase process: manpower

supply phase, patient preparation phase, patient removal phase, rest and recovery

phase, and manpower resupply phase. Research findings are reviewed and a research

agenda is proposed.

17. KEY WORDS (six to twe lve entries; alphabetical order; capitalize only the first letter of the first key word unless a proper name;

separated by semicolons)

Building codes; building evaluation; elderly; fire safety; handicapped occupants;

health care facilities; nursing homes; user needs.

18. AVAILABILITY Qx} Unlimited 19. SECURITY CLASS

(THIS REPORT)

21. NO. OF j PRINTED PAGES r

f 1 For Official Distribution. Do Not Release to NTIS UNCLASSIFIED

i 64

| | Order From Sup. of Doc., U.S. Government Printing Office, Washington, DC

20402, SD Stock No. SN003-003-

20. SECURITY CLASS

(THIS PAGE)

22 . Price

| | Order From National Technical Information Service (NTIS), Springfield, V A. 22161 UNCLASSIFIED $5.25

USC O MM- D C
- ” .v ll . • '
!
II