Fire safety in healthcare

Fires in hospitals and care homes are less common than they were fifty years ago, thanks to sprinklers, fire-resistant materials, smoke-free rules and better building design. But when they happen, they are dangerous in a way that fires in most buildings are not, because so many people inside cannot escape by themselves. Fire safety in healthcare therefore has two goals at once: prevent fires, and make sure that if one starts, the people in the building, especially patients and residents, are protected where they are while the fire is controlled. This lesson covers how fires start in healthcare settings, how buildings are designed to contain them, and what every worker does when the fire alarm sounds.

How fires start in healthcare

Every fire needs three things: fuel, heat (an ignition source) and oxygen. Remove any one and the fire cannot start or continue. Hospitals have plenty of all three.

• Fuel: linen, mattresses, paper, packaging, alcohol-based hand rub and skin prep solutions, flammable liquids in laboratories and pharmacies, plastics in equipment, and waste.
• Heat: electrical faults in equipment, overloaded power bars and damaged cords, heating and cooking appliances, lighting, electrosurgical units and lasers in operating rooms, and smoking materials.
• Oxygen: the air, plus piped and bottled medical oxygen, which is in use in almost every patient area.

Oxygen deserves special attention. It does not burn, but it makes everything else burn faster and hotter. In an oxygen-enriched atmosphere, such as under a drape near a patient receiving oxygen, inside an oxygen tent, or in a room with a leaking connection, materials that would only smolder in normal air can burst into flame, and a small spark can start a fire. Hair, gowns and bedding near a patient's face can hold extra oxygen for some time after it has been turned off.

The most common causes of fires in healthcare facilities are cooking, electrical problems and smoking. Patients who smoke while on oxygen, or who hide smoking materials in their rooms, are a known risk on medical units and in long-term care. Laundry dryers, where lint builds up, and kitchens are other common places for fires to start.

Surgical fires

Operating rooms bring the three parts of the fire triangle closer together than anywhere else. The oxidizer is oxygen or nitrous oxide, sometimes delivered at high concentration near the patient's face. The ignition sources are electrosurgical devices, lasers, fiber-optic light cables and drills. The fuels are alcohol-based skin preps, drapes, gauze, the patient's hair and even the patient's own tissues and gases. Surgical fires are rare but devastating, often causing serious burns to the patient's airway or face.

The surgical team prevents fires by managing each side of the triangle:

• Oxidizer: use the lowest oxygen concentration that keeps the patient safe, especially for procedures on the head, neck and upper chest; avoid open delivery of oxygen under drapes where possible; arrange drapes so oxygen does not build up near the surgical site.
• Ignition: keep electrosurgical tips in a holster when not in use; never let a light cable rest on drapes; use lasers and electrosurgery only when needed and at the lowest effective power.
• Fuel: let alcohol-based prep solutions dry completely for the time stated on the label, and prevent them from pooling under the patient or soaking into drapes and hair; moisten sponges and gauze used near ignition sources.

Before each operation with a high fire risk, the team does a fire risk assessment as part of the surgical safety checklist and agrees who will do what if a fire starts: stop the flow of oxygen, remove burning materials from the patient, put out the fire with saline or water, and care for the patient.

How healthcare buildings contain fire

Healthcare buildings are designed around a strategy usually called defend in place. Instead of relying on everyone getting out, the building is divided into compartments that hold back fire and smoke long enough for staff to move patients sideways to a safe area on the same floor, and for the fire department to put the fire out.

The main features are:

• Fire and smoke compartments: fire-rated walls and floors divide the building into sections, and each floor of patient areas has at least two smoke compartments, so patients can be moved horizontally away from the fire.
• Fire doors and smoke barrier doors: doors in these walls close automatically when the alarm sounds, released by magnetic hold-opens. A door that is wedged open or blocked by a cart defeats the whole design.
• Sprinklers: automatic sprinklers control or put out most fires before they spread beyond the room where they started. Each head opens on its own when heated, so only the sprinklers over the fire discharge.
• Fire alarm and detection: smoke and heat detectors and manual pull stations sound the alarm, release door hold-opens, shut down some air handling units, recall elevators and signal the fire department.
• Exits and evacuation routes: protected stairwells and exits lead outside or to another part of the building.

In the United States, hospitals and nursing homes that take part in Medicare and Medicaid must meet NFPA 101, the Life Safety Code, adopted by CMS, along with NFPA 99, the Health Care Facilities Code. NFPA 101 requires fire drills in healthcare occupancies at least once per quarter on each shift, and CMS has required automatic sprinklers throughout nursing homes since 2013. State fire marshals, CMS surveyors and accrediting bodies inspect these features.

Keeping the protection working

The building can only protect people if everyday habits do not undo it. Many of the problems found in fire inspections are simple:

• Fire doors wedged open, or blocked by beds, carts and linen hampers so that they cannot close.
• Equipment stored in corridors, which narrows exit routes and blocks the movement of beds.
• Items stored within 18 in (45 cm) of sprinkler heads, which stops the spray from reaching the fire.
• Missing or damaged ceiling tiles, which let smoke and heat bypass the sprinklers and spread above the ceiling.
• Extension cords and power bars used as permanent wiring, or patient equipment plugged into household power bars.
• Extinguishers and pull stations blocked, missing or overdue for inspection.
• Exit signs out and exit doors locked or chained in ways not approved in the fire plan.

Tom Bergstrom checks these items during the monthly safety committee inspection, and the 4 West inspection last spring found two wedged fire doors, a ceiling tile missing outside room 409 and a linen cart parked in front of the extinguisher. None of these would have caused a fire, but all of them would have made a fire worse.

RACE: what to do if you find a fire

Northbridge, like most healthcare facilities in North America, teaches the RACE sequence for responding to a fire:

• Rescue: move anyone in immediate danger away from the fire, starting with the person in the room where the fire is. Do not put yourself in danger to do it.
• Alarm: pull the nearest fire alarm and call the emergency number, giving the exact location. Shout to alert people nearby.
• Contain: close the door to the room on fire, and close all doors in the area. A closed door holds back smoke and heat for many minutes and is one of the most effective things you can do.
• Extinguish or evacuate: if the fire is small, such as a wastebasket, and you are trained and have a clear exit behind you, use an extinguisher. Otherwise, move patients away from the fire, beyond the next set of fire doors, as directed by the person in charge.

Some hospitals order the first two steps differently, or teach the steps in a different language, but the content is the same: protect people, raise the alarm early, close doors, then fight a small fire or move away.

Using an extinguisher

Portable extinguishers are for small fires only, in their early stages. A fire that is larger than a wastebasket, that is spreading, or that is producing thick smoke is beyond what an extinguisher can handle. Before using one, make sure the alarm has been raised, that you have a clear way out behind you, and that you know which type of extinguisher you have.

• Multipurpose dry chemical (ABC) extinguishers are the most common in hospitals and work on ordinary materials, flammable liquids and electrical fires.
• Carbon dioxide extinguishers are used near sensitive electrical equipment because they leave no residue.
• Water mist extinguishers made of non-magnetic materials are used in and near MRI rooms, because a steel extinguisher would be pulled into the magnet.
• Wet chemical (Class K) extinguishers are used in commercial kitchens for cooking oil fires.

Use the PASS sequence: pull the pin; aim the nozzle at the base of the fire, not the flames; squeeze the handle; sweep from side to side across the base. Most extinguishers empty in 10 to 20 seconds, so if the fire is not out quickly, leave, close the door and let the fire response team and fire department take over.

When the alarm sounds on your unit

When the fire alarm sounds, staff on the unit where the fire is follow RACE. On other units, the procedure is different: staff close all doors, clear corridors of equipment, check that patients are safe, prepare to receive patients from the affected area, and listen for announcements. Elevators are recalled and must not be used unless the fire department directs otherwise.

The oxygen zone valves on each unit control the oxygen supply to a group of rooms. Turning one off can stop oxygen feeding a fire, but it also cuts oxygen to every patient in that zone. At Northbridge, only the charge nurse or a respiratory therapist decides to close a zone valve, after making sure that patients who need oxygen are switched to portable cylinders.

Northbridge runs fire drills on every unit and every shift. After each drill, the unit records how long key steps took. Sarah MacLeod reviews 4 West's drills each quarter.

# 4 West fire drills: seconds from alarm to each step
drills = [
    # shift, alarm to doors closed, to corridor clear, to staff at
    # meeting point, oxygen check done
    ("day",     45,  95, 120, 150),
    ("evening", 60, 130, 150, 200),
    ("night",   90, 210, 180, 260),
    ("day",     40,  80, 110, 140),
    ("night",   75, 190, 170, 240),
]
TARGETS = (60, 120, 180, 180)
STEPS = ("doors closed", "corridor clear", "at meeting point", "oxygen check")

for shift, *times in drills:
    late = [s for s, t, goal in zip(STEPS, times, TARGETS) if t > goal]
    print(f"{shift:8}" + "  ".join(f"{t:4}" for t in times),
          "late: " + (", ".join(late) if late else "none"))

day       45    95   120   150 late: none
evening   60   130   150   200 late: corridor clear, oxygen check
night     90   210   180   260 late: doors closed, corridor clear, oxygen check
day       40    80   110   140 late: none
night     75   190   170   240 late: doors closed, corridor clear, oxygen check

The pattern was clear: both night drills missed the targets for closing doors, clearing the corridor and completing the oxygen check, and the evening drill missed two of them. With fewer staff, the night team had to clear the equipment stored in the corridor before they could close the smoke barrier doors and move beds. The fix was not more training but less clutter: the unit found storage rooms for the two lift slings, the vital signs machine and the extra chairs that lived in the corridor, and the next night drill cleared the corridor in 110 seconds.