Fire safety in the ICU

Fire safety in the ICU is a part of the broader disaster management topic, which includes answers to questions like "what should I do if the hospital oxygen supply fails" or "how to disarm the colleague who brought a gun to work". The specific fire scenario has come up twice already, in Question 3 from the first paper of 2000 and Question 8 from the second paper of 2011. For the first appearance, the college answer was extremely brief and resembled instructions shouted over the public address system ("Shut all doors and windows. Turn off oxygen outlets.") The second time, bureaucratic elements among the examiners insisted that  an audit-like "review of fire policy and implementation of staff education and simulation exercises" would be an essential part of the response to a raging inferno threatening to consume you. 

What literature is there to guide the candidate? The best, by far, is the recent statement from the  UK Association of Anaesthetists and the Intensive Care Society (Kelly et al, 2021). NSW health also 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). Guidelines were also written for the British NHS in 1998 and these are available online. Again, these reiterate the above approach.

In summary:

Response to a fire in the ICU:

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.

Response to a fire in the ICU

Major objectives are:

• Protect the staff as the priority. This is a strange item to emphasise, but it needs to be established first and at the front, that your main responsibility, to begin with, is to yourself and to your colleagues, and to the patients second. It does however create the environment for chilling ethical and moral calculus performed instantly by frightened people running through smoke, the sort of spur-of-the-moment decisions that could really haunt you in the years to come. "They should make an emergency
  ‘dynamic risk assessment’ weighing up their responsibilities to their patients against the risk to their own life", Kelly et al recommend. 
• 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.

Evacuation

• 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
• The concept was first used to describe the rapid emptying of inpatient beds to make way for large volumes of ED admission (Pollaris et al, 2016).
• In the context of a fire, this may mean that some of the sicker patients may die by being left in the blazing ICU. How can this be defended? One might argue that each person's desire to stay alive is as important as another person's, irrespective of the quality of their life (or the expected duration of their life). However, the intensivist frequently flaunts this principle by withdrawing care on patients when there is overwhelming evidence of clinical futility. In this case, the withdrawal would be on the grounds of overwhelming clinical benefit to other patients. Consider how unreasonable it would be for an ICU patient to argue, from their burning bed, that their right to survival is more important than the right of others, including staff and visitors. These issues are tackled in great depth in Law and Ethics in Intensive Care, by Danbury and Lawson (2010).

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)

Bureaucracy and finger-pointing

Obviously, the examiners will favour an approach which demonstrates administrative maturity. Such an approach involves revising local unit policies and forming a working party of auditors while the embers are still warm. A sufficiently mature approach would involve the following essential elements:

• 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)
  • Increase the ventilation of the ICU (more than 10 air exchanges per hour) to prevent the concentration of oxygen in enclosed patient spaces
• 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

History of ICU fires

There a few case reports of fires in the ICU which may be informative. Sankaran et al (1991) offers a somewhat dated report about an electrical fire in 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). Moreover they were little and carrying them out was fairly straightforward. There were no fatalities.

 The fire actually followed an earlier incident where smoke was found issuing from a lint-filled electrical socket; all sockets were vacuumed but nobody bothered to check inside the cupboard where the electrical pipes and oxygen conduits mingled in a lint-heavy atmosphere. Somehow, a pressure difference between the cupboard and the rest of the ICU entrained air, collecting lint like the heatsink on your CPU. Apart from this design flaw, the authors complained that providing oxygen to the infants was difficult because portable sources were not readily available (unthinkable, almost thirty years since - in the local unit at least two cylinders are at all times in every room).

Kelly et al (2014) describes another frightening incident, where compressed oxygen somehow suddenly ignited inside a cylinder valve while the tank was laying on a patient's bed:

...a loud bang was heard, sparks were seen and the cylinder immediately caught fire, with four foot flames coming from the cylinder’s body... The bedding and mattress ignited, rapidly followed by the bed curtains, the flooring and ceiling tiles. The fire alarm was activated, and the patient on the burning bed was pulled to safety by two nurses and a doctor. Another nurse was trapped in a corner by the flames, and crawled under the burning bed to escape. Within ten seconds the ICU was filled with thick, black, acrid smoke and visibility was reduced to less than a metre.

Nobody died. The situation was managed very well. All ICU staff and visitors as well as eleven of twelve total patients were evacuated within seven minutes, left on a service road near the ICU. In the haste, CVCs and nasogastric tubes were occasionally pulled out by accident. 

Interesting points were made in this article, as it describes a contemporary scenario:

• The fire occurred at 19:20, but by 19:50 the social media and the press were already aware of the situation, and security officers were required to manage scene access.
• "All staff involved in the fire were removed from duty: some required persuasion, and in a minority, insistence was required."
• When the police arrived, instead of working with the staff to re-open the ICU they cordoned off the area and established a crime scene, preventing anybody from accessing vital equipment and supplies.
• Short term ICUs were established in the recovery room and the emergency department; some patients were moved offsite to other ICU facilities
• The next day's elective admissions were cancelled, to allow for recovery room space
• Even though fire-damaged, one half of the ICU was re-opened on the next day, and some of the transferred patients were repatriated.
• Many staff suffered nightmares and flashbacks for months afterwards, with other features of PTSD suggesting that formal counselling would be an appropriate step

These case reports feature situations in which the health service works together to rescue a potentially disastrous situation. Neither report features any fatalities. However, patients can die in ICU fires. In October of 2016 a fire broke out in the ICU of Sultanah Aminah Hospital (Johor Baru). Seven people became trapped in the building and six of them died (all of them ICU patients). An even larger conflagration at the Institute of Medical Sciences and Sum Hospital (Bhubaneswar, eastern India) claimed the lives of 23 people, caused by a short circuit in a dialysis machine. 

What have we learned?

In a comment which responds to Kelly et al, Wigmore (2014) made the following recommendations:

• Build your ICU on the ground floor to facilitate "horisontal" evacuation of bedbound patients
• Three escape routes, leading to three separate safety areas
• Safety areas to be well away from buildings (burning debris tend to fall on people)
• Each bed must be equipped with a fire sheet
• Each bedspace should have an evacuation box containing emergency drugs, fluids and intubation equipment.
• All staff to be trained in the "major incident plan", which frequently nobody is aware of