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.
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.
Major objectives are:
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:
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:
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.
In a comment which responds to Kelly et al, Wigmore (2014) made the following recommendations:
Kelly, F. E., et al. "Fire safety and emergency evacuation guidelines for intensive care units and operating theatres: for use in the event of fire, flood, power cut, oxygen supply failure, noxious gas, structural collapse or other critical incidents: Guidelines from the Association of Anaesthetists and the Intensive Care Society." Anaesthesia (2021).
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.