Preparation for dealing with fires in hospitals goes well beyond the RACE and PASS acronyms that all hospital staff are familiar with. A recent article on firefighting in hospitals (Stiene 2014) got our attention for its excellent recommendations and also piqued our interest in the need for special attention to certain areas. All hospitals regularly have fire drills and the local fire department responds to all these drills. And, yes, local fire and police departments do participate in joint planning for fires and other disasters with hospital staff.
Stiene discusses life safety codes relating to fires from the perspectives of the National Fire Protection Association (NFPA), CMS, and The Joint Commission. He notes striking progress made in hospital fire safety, noting that from 1980 to 1984 fire departments responded to 7100 hospital fires annually on average (with 5 deaths per year) compared to only 1400 hospital fires and one death per year from 2006 to 2010). Two of the biggest factors for the decrease have been smoking bans and installation (at original construction or by retrofitting) of automatic sprinkler systems.
Stiene discusses how hospitals evacuate patients, visitors and staff that are capable of evacuating safely and also how hospitals manage those patients not capable of evacuating on their own. He discusses the horizontal and vertical evacuation modes (moving patients to an adjacent compartment safe from smoke) and “defend-in-place” strategies for patients that must remain in place. All require responding firefighters to have an intricate understanding of the hospital’s life safety plan, its smoke compartments, sprinkler coverage and ratings, alarm detection and localization systems, medical gas systems, electrical systems and backup generators, HVAC and air handling systems, connections between various buildings, location of various shutdown devices, and many others. They also need a detailed understanding of how disruption of power will impact various areas of the hospital. Many of these resources need to be available in real time at the hospital fire command center but pre-incident planning between the hospital staff and fire department is critical. We’ll add that we often see changes made in hospitals, particularly those that do not require certificates of need or approval of state or local regulatory bodies, that don’t get promptly communicated to local fire departments.
Fire departments also need to understand the roles of the house supervisor and the administrator-on-call, the latter often not being on-site initially when the fire company responds.
Stiene notes that having a predetermined fire command center and communication protocols are very important factors that need to be part of the pre-incident planning between hospitals and fire departments. Such pre-incident planning meetings need not just the hospital fire liaison but also key staff from clinical (medical and nursing) departments and also representatives from safety, security, and engineering departments. Because of issues we’ll note later we also recommend the importance of including representatives from the lab, pharmacy and radiology. Stiene notes it is important for the fire department to train all its firefighters on these plans. He notes that may need to include mutual-aid fire companies as well. We’ll comment that it must be difficult for smaller and volunteer fire companies to always ensure their new members are fully up-to-date on the plans. The latter is a bit like hospitals ensuring that any new and/or temporary nursing staff are fully up-to-date on the most critical protocols and related issues.
There are a couple other recent resources on hospital fires. The Pan American Health Organization and WHO have published an excellent fire prevention and evacuation guide “Hospitals Don’t Burn!” (Pan American Health Organization 2014). And Gregory Bierster from the FDNY (Bierster 2011) published a study on hospital fires in the New York City area.
Bierster had some good lessons learned from the NYC hospital fires. It is important to keep track of patients not just during a fire but also being prepared before a fire. He notes that many hospitals can’t easily tell the fire department which patients are ambulatory and which are not. Obviously, keeping an up-to-date roster of all patients’ ambulation capabilities would be important. He also found that evacuation devices for those patient who are not ambulatory were often not readily available or their locations were not readily apparent. He also recommends wearing of vest by critical hospital personnel so the incident command can easily recognize them.
When a fire occurs in a hospital, certain staff members are responsible for assisting with the evacuation, closing the doors, searching, and shutting down medical gases. Bierster provides a survey of staff assignments for these functions.
Bierster notes the vaious types of hospital evacuation that have taken place in NYC hospitals: vertical (5%), horizontal (12%), and sheltered in place (17%) and that nationally, 31% of hospitals had a situation in which patients were evacuated horizontally, 21% had patients moved to another floor, had 42% had a situation where patients had to be partially evacuated outside the building.
The Pan American Health Organization and WHO (Pan American Health Organization 2014) emphasize that the initial steps to protect hospitals against fires are prevention and suppression and that complete evacuation of patients should be avoided unless absolutely necessary. They note that evacuation maps should be posted at the hospital’s main access points to clearly identify egress routes and that egress routes and exits should be clearly identified using internationally accepted identifying signs. They provide good examples of a Hospital Incident Command System Structure and tables with how to prioritize patients for evacuation.
They stress that there should be designated “patient tracking” staff who are responsible for tracking and reporting on the location of patients throughout the evacuation process, including:
They also discuss having an assembly point/holding area, which is a place or set of places where patient care units gather (outside the main clinical buildings of the hospital) to receive basic care and await transfer or reentry back into the hospital. Generally, only essential care resources are available in these areas.
The Pan American guide also has several useful tools, including:
But there are several areas only briefly mentioned by these 3 resources and several other scenarios that merit special discussion and drills with your local fire (and police) departments.
The MRI Suite
First and foremost is the MRI suite. And keep in mind that the MRI suite may also be: 1) owned and operated under a third party arrangement (eg. group of physicians, university, etc.) even though it is physically based in your hospital and 2) sited in a trailer or truck outside the hospital per se but on the hospital grounds.
There are some excellent resources available on the issue of fires in the MRI suite, including some from MRI safety guru Tobias Gilk (Gilk 2012). Gilk describes two fires affecting MRI units. One, in England, resulted in disruption of the circuits that would allow activation of the remote “quench” buttons that would allow the unit to be shut off. Hence the fire raged for days and the MRI active magnetic field persisted for 10 days amidst the rubble of an otherwise totally destroyed facility. The second, in Pennsylvania, had a much more successful outcome when the MRI staff evacuated the patient, extinguished the fire with an “MR Conditional” fire extinguisher before the fire department arrived, and successfully quenched the magnet. Gilk discusses multiple issues related to the construction of the MRI units, availability of appropriate fire extinguishing gear and training of staff on how to use the gear. But he also discusses the need for fire emergency policies and procedures specific to MRI and the need to do preplanning for such events with hospital staff and the fire departments who will respond.
Probably the biggest issue for firefighters responding to a fire (or other incident) in an MRI suite is an understanding that ferromagnetic materials may turn into projectiles or missiles on exposure to the intense magnetic field of the MRI. There are a number of tools and equipment used by firefighters and law enforcement personnel that may become projectiles in the MRI suite (SUNY Stony Brook 2011). Firefighters may carry fire extinguishers, self-breathing apparatus and oxygen tanks, axes, pics and “pike” poles that may become projectiles in the MRI unit. In addition the fire hose nozzles and hose couplings may become projectiles. Law enforcement personnel may carry guns, knives, handcuffs, flashlights, and clipboards that have similar potential to become deadly missiles. Gill, in commenting elsewhere on the Pennsylvania MRI fire, noted a case where a firefighter lost his axe to the pull of an MRI when he was ventilating the roof of a building (Darragh 2011).
An article on the fire department response to MRI emergencies (Concordnc.gov) discusses both the ferromagnetic/projectile risk and the hazards of the “quench” (release of the cryogenic gases when the MRI is shut down). It discusses many of the construction and equipment issues, including the need for a non-metallic fire extinguisher. It also describes the importance of signage warning about metallic objects and avoiding entry to the critical areas (see our prior columns on MRI safety listed at the end of today’s column). The article goes on to discuss how to fight large fires from a safe distance and what to do after the fire is extinguished, including considerations for the fire investigators. An article for a continuing education course for firefighters provides a comprehensive review of MRI-related firefighting issues and a list of questions to ask during a pre-incident planning session (Jones 2014). Good examples of MRI Safety Policies with recommendations about fires are provided below (University of Louisville, SUNY Stony Brook 2011). The SUNY Stony Brook slides nicely describe multiple other facets of MRI safety as well.
In our February 1, 2011 Patient Safety Tip of the Week “MRI Safety Audit” we mentioned that an extensive audit found fire drills were conducted in only 64% of MRI facilities in the VA system (VA 2011). Fire drills clearly need to take place in MRI facilities, whether in-hospital or stand-alone. Moreover, pre-incident planning for fires (and other emergencies) needs to take place between your organizations and your local fire (and law enforcement) departments.
Behavioral health is another major area with special concern. Also many fires occur in behavioral health units. Check just about any such unit and you will find “contraband” smuggled in by patients and/or their friends or family. Some of the more popular “contraband” items are cigarettes and matches or lighters.
And there may be patients on behavioral health units that are potentially violent. Many of the fire and police tools and equipment we mentioned under the MRI section are also potentially dangerous on behavioral health units. We have seen firefighers’ axes laid down on the floors and fire extinguishers (which could also be potentially used as weapons) left unattended during response to fires on such units.
We’ve seen cases where patients on behavioral health services have started fires with the intention of absconding during the subsequent evacuation. Also, in our December 2010 What’s New in the Patient Safety World column “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units” we mentioned a case where locked doors automatically opened when the fire alarm went off and a patient then got access to a rooftop for a suicide jump.
Another consideration is the patient who, because of their mental health issues, refuses to leave the unit. Staff has a priority to get patients out of harm’s way. They must attend to getting as many patients away from the danger as quickly as possible. This is where head counts are extremely important and where the staff assigned with tracking patients must be able to tell the responding firefighters that someone is still on the unit.
Firefighters are probably much more aware of hazardous materials and better trained to deal with them than your average healthcare worker. Bierster noted that the hazardous material which caused the fire most frequently was flammable gas (23%), combustible gas (15%), chemical leak or spill (15%), flammable liquid (8%), bio hazard (8%) or other types of chemicals not listed on the survey (30%) (Bierster 2011). But keep in mind that hazardous materials may be encountered that were not involved in causing the fire. One may encounter hazardous chemotherapy agents if a fire involves pharmacy or hazardous radiation if a fire involves a radiology or nuclear medicine suite.
The recent Ebola “crisis” also raises special concerns regarding response to fires when hazardous materials or transmissible diseases are present. As above firefighters are probably much more aware of hazardous materials and are better trained to deal with them than your average healthcare worker. But it still takes a coordinated effort by both to safely deal with a fire when a patient in contact isolation is located in an area where there is a fire. How many hospitals that have such units have a similar place on an adjacent unit to which patients would be evacuated in the event of a fire? Your pre-incident planning should take such scenarios into account.
Lastly, we’ve previously discussed some scenarios when fire alarms have or have potentially occurred in conjunction with other events, hence our term “dual scenarios”. In the section above on behavioral health we noted how fires or fire alarms on such units have been associated with patients absconding or committing suicide.
Another possible dual scenario has to do with infant abductions. In our September 4, 2012 Patient Safety Tip of the Week “More Infant Abductions” we noted that the usually locked doors on the maternity unit may automatically unlock during a fire alert and that potential abductors may be aware of that. We suggested you might even consider doing a “Code Pink” (abduction) drill immediately following a fire alert drill.
Clearly, there are important issues to consider when you meet with your local fire department to pre-plan for potential fires and other emergency situations. Also, you should meet with them to debrief after every event they respond to, whether it is a real fire or not.
Some of our prior columns on patient safety issues related to MRI:
Steine M. Firefighting in Hospitals. Fireengineering.com 10/7/2014
Bierster G (Fire Department, City of New York, New York). Improving Fire and Life Safety in Hospitals. United States Fire Administration. 2011.
Hospitals Don’t Burn! Pan American Health Organization, 2014.
Gilk T. MRI Fire Safety. The Radiant 2012; Mar/Apr 2012
SUNY Stony Brook. MRI Safety, Policies and Procedures. SUNY Stony Brook. Social Cognitive, and Affective Neuroscience (SCAN) Center. Updated: September 2011
Darragh T. MRI fire underscores need for education and oversight. St. Luke's incident was handled deftly, but experts say such events can be disastrous. Morning Call (Lehigh Valley, PA) December 30, 2011
ConcordNC.gov. Fire Department Response to Emergencies Involving Magnetic
Resonance Imaging (MRI) . Magnetic fields can severely hamper firefighter efforts
Jones C. Magnetic Resonance Imaging Safety for Firefighters. Fireengineering.com 2014; 6/16/2014
University of Louisville. MRI/NMR Safety.
Department of Veterans Affairs Office of Inspector General. Evaluation of Magnetic Resonance Imaging Safety in Veterans Health Administration Facilities. Report No. 09-01038-77. January 26, 2011
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