The Nursing Home Evacuation During a Wildfire
A fast-moving wildfire is 6 miles from a 120-bed skilled nursing facility and moving with a forecast wind shift toward the facility within 3 hours. The facility has 96 residents: 22 are independent, 40 require assistance with mobility, 18 have advanced dementia, 10 are on oxygen, and 6 are ventilator-dependent in a small subacute unit. The facility has two paratransit vans (12 passengers each, no stretcher capability), one contract ambulance on standby, and a mutual-aid agreement with a hospital 25 minutes away. The county EOC has declared a shelter-in-place order for the surrounding area but the fire behavior model shows the facility in the path. The administrator asks you, as the on-call medical director, whether to shelter in place or evacuate, and how.
1. Should the facility shelter in place or evacuate? Defend the decision using the hazard timeline, resident acuity, and transport constraints.
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Evacuate - and begin now. Reasoning:
- Timeline: 3 hours to impact is shorter than the time needed to move 96 residents with this acuity mix, especially ventilator patients. Shelter-in-place is only defensible when the building can be made smoke-tight and the hazard will pass; a fire moving toward the facility with a wind shift does not meet that test, and the county order covers the surrounding area, not a guarantee for this building.
- Acuity: 6 ventilator-dependent residents need critical-care transport (ventilator, oxygen, suction, trained staff). 10 oxygen residents need portable O2. 18 dementia residents need 1:1 supervision to prevent wandering. 40 mobility-impaired need stretcher or wheelchair transport. Two 12-passenger paratransit vans and one ambulance cannot move this population.
- Conclusion: shelter-in-place is a false economy here; the fire model puts the building in the path. Evacuate in priority tiers and request transport through the EOC immediately.
Priority order: (1) ventilator and critical-care residents to the hospital with ICU capability; (2) oxygen-dependent and stretcher-bound; (3) dementia and mobility-impaired; (4) independent residents by van or bus.
2. Draft the evacuation plan's transport and receiving assignments, and identify the two failure points most likely to derail it.
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Transport assignments:
- Ventilator patients (6): contract ambulance plus mutual-aid ALS units requested via EOC; each patient travels with a respiratory therapist or nurse and a portable ventilator with battery. Destination: hospital with ICU beds.
- Oxygen-dependent (10): paratransit van with portable O2 cylinders and a nurse; destination hospital or receiving facility with O2 supply.
- Stretcher/wheelchair (40): paratransit vans in multiple trips plus requested wheelchair-accessible buses; each trip carries a staff escort.
- Dementia (18): supervised transport with identification wristbands and a manifest; do not mix with independent residents.
- Independent (22): bus or van to a designated shelter; register names at departure.
Two most likely failure points:
- Transport shortfall - the facility's own fleet cannot move 96 residents; without EOC-pushed assets the evacuation stalls. Mitigation: request buses and ambulances before the first van leaves, and stage a loading zone.
- Manifest and tracking loss - residents arrive at multiple destinations with no unified list. Mitigation: a single manifest printed and updated at each departure, with a runner transmitting names to the EOC and receiving facilities. Secondary risk: staff not trained on ventilator transport; assign the subacute unit's own staff to those patients.