Management of hospital operations during a wildfire has become commonplace for caregivers in Sonoma County. This field report aims to compare the 2017 Tubbs Fire incident and the more recent 2019 Kincade Fire incident and highlight operational interventions as a way to help physician leaders faced with similar circumstances in the areas they serve.
ABSTRACT: Management of hospital operations during a wildfire has become commonplace for caregivers in California’s Sonoma County. This field report compares the learnings from the 2017 Tubbs wildfire incident and the 2019 Kincade wildfire incident. The specific areas of opportunity to manage hospital operations include disaster preparedness, housing, capacity management, and caring for caregivers. Operational interventions such as leading hospital incident command, securing housing, managing surge, and providing support to employees whether it be through organized rounding or financing support helped Sonoma County manage through the Kincade incident.
Management of hospital operations during a wildfire has become commonplace for caregivers in Sonoma County. This field report aims to compare the 2017 Tubbs Fire incident1 and the more recent 2019 Kincade Fire incident and highlight operational interventions as a way to help physician leaders faced with similar circumstances in the areas they serve.
PROBLEM AND SIGNIFICANCE
California’s St. Joseph Health, Sonoma County, is anchored by two core facilities: Santa Rosa Memorial Hospital (SRMH) and Petaluma Valley Hospital (PVH). Located about 55 miles north of San Francisco on Highway 101, SRMH is a 338-bed acute care hospital and the region’s only Level 2 trauma center. Serving Sonoma, Napa, Mendocino, and Lake counties, it provides a broad array of services including a Level 3 neonatal intensive care unit, cardiac surgery, and neurosurgery.
PVH, 40 miles north of San Francisco, is an 80-bed general acute care hospital and provides a family birth center, general surgical services, and critical care.
In October 2019, the Kincade Fire threatened the residents of Sonoma County. Although this fire was less destructive to physical structures and human life in comparison to the Tubbs Fire in 2017,1 it consumed more acres of vegetation (see Table 1).2 In anticipation of fire danger, which triggered planned evacuations and power shutdowns, the two hospitals in Sonoma County went on alert (see Figure 1). At the Kincade Fire’s peak, the sheriff’s office in Sonoma County reported that 180,000 residents of the county — nearly four in 10 people — were ordered to leave their homes and businesses due to the unpredictable spread of the fire. In addition, Pacific Gas and Electric Company (PG&E) in Northern California planned power shutdowns that would affect more than 2 million residents in 35 counties.
On Wednesday, October 23, 2019, a vegetation fire north-east of Geyserville reportedly consumed 10,000 acres and destroyed two structures. Within the next two days, air quality worsened, Geyserville residents were ordered to evacuate, the acreage of the fire doubled, and the number of structures destroyed increased to 49.
At 1:27 p.m. on Saturday, October 26, incident command was opened at SRMH in accordance with the disaster preparedness process and as part of the hospital incident command system. Immediately, roles were assigned with the goal of maintaining safety for caregivers and normal hospital operations. Twice-daily briefings were held and included reports from the public information officer, liaison, and operations, planning, logistics, and finance departments. These efforts were coordinated with the partnering 60-bed facility in Petaluma, 208-bed facility in Napa, and county emergency operations center. Following the process for the hospital incident command system was critical to the success of managing the Kincade Fire incident.
INTERVENTIONS AND SOLUTIONS
Disaster Preparedness (Fire and Planned Power Shutoff)
Many of the lessons learned in 2017 prepared Sonoma County for the Kincade Fire. The Tubbs Fire experience taught staff that air quality in the hospital can be significantly affected by the fires; therefore, access was restricted to the Emergency Department (ED) and main lobby a day prior to opening incident command. On the day incident command was opened, four air scrubbers were deployed and an additional 10 were delivered.3
A lack of primary care services because of the mandatory evacuations and planned power shutoff presented challenges to caregivers who were experiencing respiratory symptoms while on the job. A key strategy to maintaining a healthy workforce was for caregivers to report their symptoms to their leader or house supervisor; the hospital respiratory therapist used those numbers to provide an assessment and arrange for a standing order of pharmaceutical medications for the caregiver. Maintaining a good air quality and a safe environment allowed both SRMH and PVH to stay in operation.
The map displayed as Figure 2, extracted from the CalFire website during the incident, provides some insight into the impact of the wildfire. The bright red dots represent active fire at its peak of activity. The evacuation areas are noted on the map. SRMH is located just above the “a” in “Santa” on the map. The yellow and brown shaded areas note the planned power shutoffs.
PG&E had planned six power shutoffs in 2019 in areas at high risk of its equipment starting a wildfire. There were two shutdowns during the Kincade Fire. The first shutdown, which lasted for three days affected 86,713 customers and 2,721 medical baseline customers in Sonoma County. The second, implemented only days after the first power shutdown, was smaller in scale and lasted two days.
The planned power shutdowns had consequences for hospital patients who required advanced imaging or elective surgery because resources were not operational at all outlying facilities during the power shutdowns. One of the dangers was that the longer the shutdowns persisted, the greater at risk patients were of having an exacerbation of a chronic condition.
Resource centers were deployed throughout the North Bay to provide back-up power. Community health workers reported that some patients were staying in place even without back-up power for their concentrator or continuous positive airway pressure devices, contributing to the capacity management challenges at both facilities. The mitigating strategy put in place at these facilities was to make power available for patients in lobbies and cafeterias. Patients who required emergency service after the resource centers closed were directed to either of these areas if they were requesting power.
Having a place for caregivers’ children was important in maintaining normal operations. Because schools and childcare facilities were closed, a conference room was converted into a daycare. Prior to the Kincade Fire, the average number of children cared for was four per day. During the Kincade Fire, the average was nine with a peak of 23 children cared for in one day.
While the 2019 Kincade Fire was not as destructive as the 2017 Tubbs Fire, the housing challenges were similar with the power shutoffs and mandatory evacuations (see Table 2). As previously mentioned, during the peak of the Kincade Fire, four in 10 people within Sonoma County were evacuated from their homes. The American Red Cross reported that 1,280 stayed in shelters when incident command was open at SRMH.
On the first day that incident command was opened, the logistics section chief reserved 20 hotel rooms for caregivers, estimating less than 10 percent of the workforce would need housing. In addition to securing hotel rooms, a labor pool was created as a part of the hospital incident command system; its role was not only to ensure the readiness and safety of the workforce, but also to compile referrals for spare rooms or apartments for displaced caregivers. Finally, a secure offsite hospital wing, which was listed on the housing hotline, gave caregivers respite.
An overriding difference between the Tubbs and Kincade fires was that when repopulation began, many residents had homes to return to. This increase in population led to a significant surge in St. Joseph Health System facilities to replace two other large health systems in Santa Rosa, which had been evacuated. Through appropriate planning, both SRMH and PVH were able to maintain normal operations.
Santa Rosa Memorial Hospital (SRMH)
During the Kincade Fire, SRMH surged when Geyserville was evacuated. Shortly thereafter, SRMH’s transfer center limited its intake to only those patients needing advanced care for cardiac disease, trauma, obstetric, or pediatric conditions. If there was a clinical rationale to have the patient come to SRMH, the incident commander pulled together key stakeholders to determine what was best for the patient considering the current conditions.
The fire began on the weekend when a negligible number of elective surgeries had been scheduled, making it easier for the hospital to respond to the mandatory evacuations of nearby Kaiser and Sutter. Among the acute care and skilled nursing facilities, 355 patients were evacuated (see Table 3). SRMH had an influx of 23 patients: 12 patients went to the Women and Children’s unit, eight went to the Neonatal Intensive Care Unit, two went to the Intensive Care Unit, and one patient went to the Emergency Department.
Given the unpredictable nature of the wildfire, with wind gusts up to 90 mph, the Kincade Fire threatened to inflict the same impact as the Tubbs Fire. After accepting the initial surge of patients, the hospital began to prepare for evacuation.
On Sunday morning, incident command at SRMH received a request to evacuate. After seeking further clarification, it was determined that the mandatory evacuation would not include the hospital because the wildfire was more than 10 miles from the facility and would need to travel through the previous Tubbs Fire area to reach the facility. The hospital incident command coordinated its briefings with the county emergency operations center throughout the remainder of the incident to further ensure safety and optimize communication.
In the weeks to come, hospital personnel, understanding that the fire had engulfed 30,000 acres, was 10 percent contained, and had destroyed more than 79 structures, canceled elective surgeries and outpatient imaging services. Leveraging the labor pool to use caregivers from Kaiser and Sutter was particularly important in the areas of the Emergency Department and labor and delivery.
Finally, physicians in the Emergency Department created a call pool that enabled colleagues to see low-acuity patients in the waiting room to improve flow. This proved to be critical following the repopulation of Sonoma County.
Two additional strategies were implemented to provide more support to the Emergency Department. The department saw 100 more patients than its average daily census of 120 during this period on several occasions (see Table 4). To meet this demand, a flexibility request was approved by the State of California Health and Human Services Agency. This request allowed the hospital’s cardiac catheterization lab pre- and post-holding area to accept patients in the afternoon. Consequently, a cohort of behavioral health patients had a distinct area in which to be cared for while meeting their needs and others in the community.
A not-so-successful tactic was putting the SRMH mobile van adjacent to the Emergency Department (see Figure 3). The mobile van has two exam rooms and is routinely used to care for our homeless population. Signage informed patients that their options were to use the mobile care van or the Emergency Department (see Figure 4). Regulatory requirements such as EMTALA made it difficult to pivot patients from the waiting room to the mobile van to empty the facility; so the mobile van was used by only a handful of patients on the two days it was stationed there.
Ultimately, as Kaiser and Sutter reopened, SRMH operations returned to its normal volumes. The incident command was able to close 14 days after the Kincade Fire started.
Petaluma Valley Hospital (PVH)
PVH’s experience mirrored that of SRMH in the Emergency Department. The facility used many similar strategies around staffing such as labor pools coordinating efforts to maintain higher-than-normal staffing levels to meet the patient volumes.
One aspect that was different was that PVH’s inpatient census was double its normal volume (see Table 5). During the Tubbs Fire the census was higher, but the census never reached 50 in 2017. Over the course of the Kincade Fire it met or exceed 50 on eight occasions. The ability to meet this demand was based on the coordinated efforts with staffing and the overall resiliency of the caregivers.
CARING FOR CAREGIVERS
The most important tactic that got each facility through this disaster was the practice of caring for caregivers. Five Days at Memorial by Sheri Fink emphasizes the importance of communication during a crisis. Fink compares the outcomes of Charity Hospital and Memorial Medical Center during Hurricane Katrina in New Orleans. When members of the disaster mortuary team arrived at Memorial Medical Center, they recovered 45 bodies from the chapel, morgues, hallways, patient rooms, and Emergency Department. Although Charity Hospital had twice as many patients and a lower ratio of staff to patients, there were fewer than 10 patient deaths.
Here is what the hospital workers attributed to Charity’s “resilience” in the face of this disaster:
- Holding meetings every four hours with everyone from “doctors to janitorial staff,” which included a talent show by flashlight, painting, and laughter.
- Category 3 hurricane drills, portable generators, oxygen-powered ventilators, and a ham radio system.
- Resilient staff. As Fink described in her book, “Charity staff was populated by crusty characters accustomed to comparatively Spartan, chaotic, and occasionally threatening conditions of an inner-city government hospital … Nearly everyone had experience getting creative with all-too-common resource limitations.”
And my favorite:
- An active effort to stem rumors. The staff was cautioned, “You can only say it if you see it.”
There are many corollaries in how Charity Hospital and the St. Joseph Health hospitals in Sonoma County operated. For example, communication briefings were held twice daily, and caregiver rounding alerted leadership to key issues such as lack of air scrubbers, staffing problems, or need for information about evacuation (see Figure 5).
Based on the Tubbs experience, a strategy was implemented to provide financial remuneration for caregivers facing mandatory evacuations. Expenses were reimbursed for receipts that included hotel accommodations, kennel expenses, grooming and hygiene, clothing, and meals related to traveling to new work locations. Also, if a facility or department was closed due to a mandatory fire evacuation and the leader was notified by the caregiver but no other work was available, the caregiver was compensated for lost work hours.
The hospital staff discussed whether to cancel the traditional Halloween costume contest because of the fire; we decided to have the contest regardless, which boosted the caregivers’ morale. Figure 6 features some of the winners. The caution tape in the background was to prevent use of unauthorized exits and to thus maintain good air quality in the hospital.
Finally, when some caregivers lamented the challenges of being open during this disaster, our leaders responded with the rallying cry, “always open” (see Figure 7). This simple phrase helped encourage our teams and build a sense of camaraderie. During one of the debriefings the unit-based council for nursing teams drafted a proposal for t-shirts. We look forward to being ready if we are fortunate enough to be operational during the next disaster.
Wildfires in northern California are becoming a normal experience in the fall. I hope this field report provides some key tactics that physician leaders can put in place in acute care facilities in the event of a disaster. Strategies include:
- Ensure the safety of patients and caregivers in emergency situations.
- Use both internal and external resources for needed housing; this can include hotels, guest rooms, or un- used patient care space. For capacity management, lean on usual strategies such as modifying transfer practices and elective surgery scheduling. Try new things for leveraging spaces like the catheterization lab or a mobile van.
- Care for caregivers, have specific strategies to learn what is going well and what is getting in the way. Trying to have fun might enable the team, like the incident command pictured in Figure 8 at the time evacuation orders were lifted, to come through better on the other side.
Finally, during the Tubbs Fire, a medical staff member shared these words by Haruki Murakami, “And once the storm is over, you won’t remember how you made it through, how you managed to survive. And you may not even be sure, whether the storm is really over. But one thing is certain, when you come out of the storm, you won’t be the same person who walked in. That is what the storm is all about.”
Chad Krilich, MD, MBA, is chief medical officer of St. Joseph Health Sonoma County, based in Santa Rosa, California.
1. Krilich C, Currie, J. What Hospital Leaders Learned from the Wildfire. Physician Leadership Journal. September 14, 2018. https://www.physicianleaders.org/news/what-we-learned-from-wildfire#:~:text=The%20lessons%20learned%20 were%20capacity,be%20better%20prepared%20for%20disasters
2. California Department of Forestry and Fire Prevention. Tubbs Fire (Central LNU Complex). https://www.fire.ca.gov/incidents/2017/10/8/tubbs-fire-central-lnu-complex/#incident-contacts. California Department of Forestry and Fire Prevention. Kincade Fire. https://www.fire.ca.gov/incidents/2019/10/23/kincade-fire
3. Health Care Facilities Maintain Indoor Air Quality Through Smoke and Wildfires. https://toolkit.climate.gov/case-studies/health-care-facilities-maintain-indoor-air-quality-through-smoke-and-wildfires
This article appeared in the Sept/Oct 2020 issue of Physician Leadership Journal.