Question 8

College Answer

• Remove all patients and staff from immediate danger area with safe disconnection of lines, monitoring and equipment and manual ventilation of patients.
• Raise the alarm – notify switchboard, stating exact location and nature of fire and activate fire alarm. Activate unit fire drill and take instructions from the designated area fire warden.
• Contain the fire closing all doors and windows. Turn off oxygen outlets.
• If fire is smaller than a waste basket attempt to extinguish with appropriate extinguishers (CO2 and dry powder) and fire blankets if safe to do so
• If fire cannot be controlled commence evacuation of patients with most stable first and most unstable last and continuing essential organ support, monitoring and essential medications.
• Depending on the extent of the fire this may be:
  • Horizontal evacuation through at least one set of fire doors to another part of the ICU or an acute care area on the same floor
  • Vertical evacuation via stairs to the floor below
  • Out of building evacuation
• Liaison with ED, OT, HDU, CCU and other high care areas in the hospital and/or neighbouring hospitals for ongoing care of the evacuated patients
• Review of incident and response to identify cause of fire and any issues with management with subsequent review of fire policy and implementation of staff education and simulation exercises

Discussion

This weird question addresses the candidate's knowledge of fire safety in the ICU.

NSW health has a policy directive which describe this in some detail. However, it is not specific to the ICU. It revolves around the RACE acronym. The main difference is the concept of reverse triage (i.e. the sickest patients evacuate last) and the idea that you may need to get other departments to look after these ventilated patients while the ICU burns. An additional feature is the need to turn off all the oxygen (and nitrous oxide).

Remove the staff and patients from immediate danger.
Alert the switch board and fire department
Contain the fire by closing doors and windows 
Extinguish the fire if it is practical and safe to do so.

And after that, you evacuate the remaining patients.Reverse triage is applied at this stage.

Guidelines were also written for the British NHS in 1998 and these are available online. Again, these reiterate the above approach. There a few case reports of fires in the ICU which may be informative. This one is from a 24-bed NICU. The patients were easily evacuated, as only five were ventilated (but one needed three people to transfer, being paralysed with pancuronium and with two chest tubes in).

Major objectives are:

• Protect the patients in immediate danger (be evacuating them, as well as your staff)
• Protect the rest of the hospital (basically, allow them to evacuate by telling them that your ICU is on fire)
• Prevent the spread of fire (by decreasing its supply of substrate, be it oxygen or fuel)
• Limit the damage to property. If it is not completely stupid to do so, make an effort to actually extinguish the fire.

Evacuate:

• Follow orders from the fire warden
• Evacuate to designated assembly points
  • On the same floor, away from the burning room; or:
  • Down the stairs, away from the burning floor; or:
  • Out of the building, away from the burning building
• Check all ICU rooms and areas (unless it is unsafe)
• Evacuation resembles inter-hospital transport:
  • Life-sustaining therapies are to be continued
  • Essential treatment is an ongoing part of ICU stay and continues while the patient is in transit or being evacuated. For instance, this means the bedside nurse can continue giving antibiotics to the septic patient while they are parked in the evacuation zone.
• Transfer to safety
  • Usually designated evacuation areas are not suited to sustaining critically ill patients in the medium-to-long term
  • For this reason, the ICU team leader needs to liase with the emergency department, high dependency units, operating theatre and recovery rooms to accept some of the patients, eg. those who need to be ventilated

Reverse triage evacuation priorities:

• Visitors first
• Stable patients next
• Unstable patients last

Fire containment

• Turn off the wall oxygen supply
• Close the doors and windows
• Extinguish the fire:
  • Only if it doe snot place yourself at risk
  • Only if you are trained to do so
  • Only if the fire is of a manageable size (LITFL suggests a waste paper basket)
  • Using appropriate extinguishers (eg. CO₂ instead of foam  or water for electrical fires)

Preventative measures

• Response to damage:  life and property
  • Open disclosure to affected staff, patients and their families
  • Appropriate use of medicolegal representation, particularly if patients or staff were harmed
  • Contact with hospital executive unit to manage the media response and to control the public perception of the situation. At Chase Farm Hospital fire, TV crews gained access to the site and pestered rescuers with demands for individual statements.
• Analysis of causes
  • Launch of root cause analysis 
  • Fire investigation may take a forensic or structural engineering pathway
  • Formation of a working party to create preventative policies and to steer the future fire safety approach
• Preventative policies
  • Make basic fire safety training mandatory for staff
  • Ensure fire extinguishers are present and staff are trained in their use
  • Ensure fire department is rapidly contractible
  • Oxygen / medical air supply shut-off valves to be obvious and easily available in a central location of the ICU
  • Easy access to emergency assembly areas; rapidly obvious emergency egress paths (eg. flashing light directing the staff which way to evacuate)
• Quality assurance program
  • Routine fire extinguisher checks
  • Fire safety committee (to ensure the policies are championed and audited)
  • Program of annual re-credentialing of fire safety for the staff
• Assessment of adherence
  • Random audits to ensure passive fire safety standards are being followed (eg. no hospital beds parked in positions where they obstruct fire exits; no wardies smoking joints in the stairwells)
  • Log of staff members who have/haven't completed their mandatory fire training
  • Random fire drills and simulation exercises

Guidelines for Fire Safety in the Intensive Care Unit; 1998, Ridley and Parry for the NHS. .

K Sankaran, A Roles, and G Kasian  Fire in an intensive care unit: causes and strategies for prevention CMAJ. 1991 August 15; 145(4): 313–315

Schaefer, H. G., R. L. Helmreich, and D. Scheidegger. "Safety in the operating theatre—part 1: interpersonal relationships and team performance." Current Anaesthesia & Critical Care 6.1 (1995): 48-53.

Reason, James. "Safety in the operating theatre–Part 2: Human error and organisational failure." Quality and safety in health care 14.1 (2005): 56-60.

Valentin, Andreas, Patrick Ferdinande, and ESICM Working Group on Quality Improvement. "Recommendations on basic requirements for intensive care units: structural and organizational aspects." Intensive care medicine 37.10 (2011): 1575-1587.

Kelly, Fiona E., et al. "Managing the aftermath of a fire on intensive care caused by an oxygen cylinder." Journal of the Intensive Care Society 15.4 (2014): 283-287.

Pollaris, Gwen, and Marc Sabbe. "Reverse triage: more than just another method." European journal of emergency medicine: official journal of the European Society for Emergency Medicine (2015).

Newdick, Christopher, and Christopher Danbury. "Reverse triage? Managing scarce resources in intensive care." Law and Ethics in Intensive Care(2010): 191.

Wigmore, T. "Evacuation of the ICU due to fire" (2014). JICS Volume 15, Number 4, October 2014

Wapling, Andy, et al. "Review of five London hospital fires and their management: January 2008-February 2009." RNational Health Service (NHS London), 2009.