Patient Safety Tip of the Week
October 21, 2014
The Fire Department and Your Hospital
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:
- An individual designated to perform head counts at the assembly
points.
- Staff assigned to check rooms and floors to ensure that they have
been vacated.
- Senior personnel in each department responsible for addressing
special hazards or concerns (e.g., turning off medical gases, performing
head counts in their areas of responsibility)
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:
- A checklist of some important fire safety inspection issues
- A list of general evacuation responsibilities of different
departments
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
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.
Hazardous Materials
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.
Dual Scenarios
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:
- February 19, 2008 “MRI
Safety”
- March
17, 2009 “More
on MRI Safety”
- October 2008 “Preventing
Infection in MRI”
- March
2009 “Risk
of Burns during MRI Scans from Transdermal Drug Patches”
- February 1, 2011 “MRI
Safety Audit”
- October 25, 2011 “Renewed
Focus on MRI Safety”
- August 2012 “Newest
MRI Hazard: Ingested Magnets”
- October 22, 2013 “How
Safe Is Your Radiology Suite?”
References:
Steine M. Firefighting in
Hospitals. Fireengineering.com 10/7/2014
http://www.fireengineering.com/articles/2014/10/firefighting-in-hospitals.html
Bierster G (Fire Department, City
of New York, New York). Improving Fire and Life Safety in Hospitals. United
States Fire Administration. 2011.
http://www.usfa.fema.gov/pdf/efop/efo43995.pdf
Hospitals Don’t Burn! Pan American Health Organization, 2014.
http://www.paho.org/disasters/index.php?option=com_content&view=article&id=1745&Itemid=1
Gilk T. MRI Fire Safety. The
Radiant 2012; Mar/Apr 2012
http://www.rad-planning.com/newsletter/2012/1203_2_MRI_fires.html
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
https://www.concordnc.gov/LinkClick.aspx?fileticket=D80nTpoqsMU%3D&tabid=166&mid=540
Jones C. Magnetic Resonance Imaging Safety for Firefighters.
Fireengineering.com 2014; 6/16/2014
http://www.fireengineering.com/content/dam/fe/online-articles/documents/FEU/Jones-June08.pdf
University of Louisville. MRI/NMR Safety.
https://louisville.edu/dehs/rad-safety/doc/mri-fire-and-cryogen-safety-pdf
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
http://www.va.gov/oig/CAP/VAOIG-09-01038-77.pdf
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