Broad overview

Introduction

Health care Units provide treatment to the sick and injured. Health care units include hospitals, nursing homes, clinics, medical, dental, eye care and diagnostics centers and others.

Some modern hospital buildings seen today resemble the futuristic building scenario in science fiction movies. A structure of fire resistant or heavy, non-combustible material construction that gives the appearance of an aseptic and sterile environment-an environment in which germs would dare not appear, or where a fire could or would never occur. One might surmise such a facility would be less of a fire risk with less to burn than a manufacturing plant or a warehouse. That is not necessarily so. Modern health care units, like business and industrial complexes, are changing. With the rapid advancement in medical technology, hospitals are now equipped with a vast array of new equipment viz. Computerized Axial Tomography (CAT) scanners, Magnetic Resonance Imagers (MRI), Linear Accelerators, Lasers, etc. Most of the high value, sophisticated diagnostics and treatment equipment are operated by complex computers. This kind of equipment requires a controlled environment with individual air handling equipment to maintain constant temperature and humidity levels.

The technological advances in the medical field have benefited people in all walks of life. However as with industry, the introduction of new technology has brought with it new protection challenges and concern.

The loss experiences of healthcare facilities the world over show that fires have resulted in large losses. Two significant factors have contributed to the losses. One is the high value of equipment per unit area. The second is that hospital equipment and supplies contain a significant amount of plastic and other combustibles. Even a small fire which is confined to a limited area may generate a lot of smoke which may damage equipment not only in that area but in areas well removed from the actual fire. This would mean repair / replacement of costly equipment which may get damaged by smoke, fire or water used for fire fighting. Equipment that is out of service even for a few days may result in extensive loss. It would prevent the hospital from performing critical diagnostic evaluations and treatment of patients. Medical supplies that are suspected of being contaminated by smoke or water may have to be disposed of. Of course the most important loss will be that of a human life. Evacuating patients is indeed a difficult task.

This article aims at identifying fire hazards and possibilities of risk improvement in health care units. It is not intended to be a comprehensive article on the subject.

Principles of Fire Prevention

When emphasis is placed on minimizing the size of a potential fire and controlling the spread of smoke, the basic approach should be to eliminate all unnecessary combustibles and reduce / eliminate ignition sources whenever possible. An International review of fire safety in health care units has shown that there are enough fires in such areas to warrant continual activity in fire loss prevention and fire and smoke spread in health care units.

Construction and Design

In minimizing the size of a potential fire and controlling the spread of smoke, the basic principle is to eliminate unnecessary combustibles. Limiting the use of combustible interior finishes will ensure reduction of fire load in the building.

Each floor should be divided into at least two connected compartments to provide horizontal means of escape from one to another. In certain areas of hospitals, the compartments may have to be further subdivided with half -hour fire resistance walls and doors. The objective of a sub-compartment is to reduce the number of people at risk and at the same time to contain the smoke spread within a smaller area of a compartment.

Other important aspects include escape routes which should be designed to remain smoke free in the event of a fire. When designing new buildings, due consideration should be given to ensure that there are no dead ends except those occurring in a room or ward, and it should always be possible to proceed away from a fire to a place of safety. In health care units, it is essential that a place of safety can be reached by evacuating horizontally rather than vertically.

Fire Hazards

A modern hospital is like a community. Besides the patients’ wards, there are chemists and small retail shops selling a variety of things like get well cards, flowers, magazines, toys, new born baby clothes etc. There are also storage areas for linen, medical supplies, records (files), housekeeping material, daily maintenance stores etc. Hospitals could have various equipment rooms. Most hospitals are equipped with laundries and kitchens. The possibilities of fire thus are many. While health care facilities are looked upon as a place for treatment of patients they are rarely thought of as places where a fire can occur. But the amount of monetary loss is often equal to or greater than those in other industrial and commercial environments even if the fire is confined to a small area.

The patients’ rooms contain mattresses, bedding, furniture, oxygen cylinders, and pipe lines carrying oxygen or nitrous oxide – all of which supply fuel to the fire.

Flammable anesthetics are found in operation theatres in hospitals. Facilities for administering these are in close proximity to the facilities for administering oxygen. Thus, in the presence of an oxygen- enriched atmosphere, when anesthesia is mixed with oxygen or nitrous oxide, it forms a mixture that can readily ignite and pose a threat to the life and safety of the people in the building.

Kitchens in hospitals cater for patients, hospital staff and visitors. Liquefied Petroleum Gas (LPG) is normally used in the kitchens and the hazards of LPG are not unknown. Special care should be taken in Kitchens where LPG is used. It is essential to know the hazards of LPG and train the employee working in kitchens in safe handling and storage of LPG.

Bedding, hospital gowns, surgeons’ apparel, and uniforms — all add to the combustible material load in laundries. Fire and smoke can spread into hospital corridors and rooms through chutes that extend from the basement to the upper stories for delivery or removal of laundry to the upper stories.

Interior fittings and furniture containing combustible materials add further fuel to a fire and can aid the spread of fire in a health care unit.

Fire Prevention

Ignition sources in health care units could be from smokers’ material, electrical sparks, frictional sparks, heated objects or static electricity. Smokers’ material like a carelessly discarded cigarette end is known to have caused several fires in health care units. It is, therefore, necessary to have a strict control over smoking by patients, hospital staff and visitors. Generally a carelessly discarded smoking material can start an incipient fire in ordinary combustible materials like paper, cloth etc and later on erupt in flames which, if not controlled in time, may lead to an uncontrollable fire.

Without electrical power perhaps one cannot think of running a health care unit. Principal causes of electrical fires in health care units could be overloaded cables and wires, improper joints and loose connections, overloaded machines, bad switch contacts, improper fuses or old insulation. This could lead to overheating, burning of insulation, arcing, short circuits and lead to fire. In areas where flammable anesthesia is present, special electrical systems must be designed. The motors and other rotating switches, circuit breakers and similar electrical equipment in such areas should be of flameproof type.

Reserve supplies of gases and flammable liquids require storage facilities with conductive floors and ventilated to the outside. The storage room should not be directly connected to the room storing oxidizing gases (nitrous oxide, oxygen, compressed air). Separate storage rooms should be provided for oxidizing gases and volatile liquid anaesthetizing agents.

Frictional or accidental sparks produced during welding or cutting operations, soldering, burning embers from vehicle exhaust, unauthorized use of electricity operated heating appliances or unlagged steam pipes running through combustible materials can lead to ignition of flammable vapours or combustible materials and result in a fire.

The main danger with static electricity is its ability to cause accidental ignition of flammable gases like ether vapour or other flammable gases like liquid vapours commonly used in the laboratories of health care units or in areas used for administering anesthesia.

Fire Protection System

The need for effective fire protection strategies for health care units cannot be underestimated. This would include an effective fire detection and protection system and implementation of more restrictive compartmentalization requirements. Some of the fire protection considerations are given below:-

• Automatic sprinkler system.
• Automatic halon fire extinguishing system.
• Smoke detection.
• Alarm actuation at a remote location.
• Portable extinguishers.
• Listed waste containers.
• One -hour fire partition area.
• Proper power isolation switch.
• No combustibles above false ceilings.
• Metal cabinet for essential combustibles.
• Preventive maintenance.
• Waterproof ceiling.

Active Fire Protection System: An effective Fire Protection System would include fire detection and alarm system, portable fire extinguishers and hose reels, hydrant systems and automatic sprinkler system.

Fire Detection and Alarm System: The principal role of an automatic fire detector is to provide early warning of fire and allow sufficient time for the occupants to escape or take defensive action to save their lives.

Manual call points are basic fire protection systems in health care premises, as raising an alarm in case of a fire can quickly and effectively minimize fire growth and its spread to different areas. However, siting of call points deserves very careful attention indeed.

Correct selection and siting of detectors are very important. Getting a timely warning depends upon installation of automatic detection systems, in areas where people cannot be relied upon to raise an alarm. Basically, detector siting should be such that there are detectors in areas where there are high fire hazards or surveillance by staff members are inadequate for early fire detection.
Smoke detectors in hospital fires are perhaps of main interest, taking into account the design and occupation of the building. Installation of detectors is very important to facilitate detection of smoke from a fire at an early stage in its development. Siting of detectors near air inlets would not be sensible. Smoke from a fire must reach the detector unhindered and the function of the detector basically is to give an alarm where smoke concentration reaches a predetermined level which depends on the sensitivity of the detector.

In recent years, “intelligent” fire detection systems are available. These are computerized systems, which regularly monitor all the detectors for response. The system also displays the exact location of an alarm condition enabling preplanned and effective fire extinguishment. Evacuation also becomes more effective within a short time. The annunciator panel should be constantly monitored and conveniently located.

Portable Fire Extingishers and Hose Reels: Portable fire extinguishers are the first line of defence during the initial stages of fire and are effective only in the incipient stage. They must hence be immediately accessible and promptly used. The specific type, number and location should be determined based on the type and design of building. Training people in their use is important. There must be regular inspection and maintenance of fire extinguishers.

Small bore hose reels connected to a dedicated source of water supply can be provided in storage areas at intervals.

Hydrant System: A riser system of an approved type should protect all floors of the building and water from a dedicated source should be available at an adequate pressure at the hydraulically most remote floor. Adequate number of hose lengths should be kept in hose boxes on each floor.

Sprinkler System: Automatic sprinklers help in controlling fire spread and providing additional time for escape. Moving patients to safety is difficult and time consuming, therefore automatic sprinklers could help reduce number of fatalities by providing more time for escape. Sprinklers should control and extinguish a fire in the area where installed and also prevent spread of fire to adjacent areas; areas having combustibles such as medical records storage, X-ray film storage and linen rooms. Patients’ rooms, office areas, kitchens parking areas need to be protected by sprinklers. It is essential that fire protection systems be maintained so as to operate efficiently during a fire.

Passive Fire Protection: Although greater importance is given to “Active” systems like, the hydrant, sprinkler or other fixed systems, the effectiveness of “Passive” protection system cannot be underestimated.

Passive systems are basically designed to limit fire spread through openings in walls and floors that are necessary for the passages in buildings and communication services. The integrity of the walls and floors is of importance to meet building regulations and prevent spread of fire and smoke. The toxic effects of burning gases like carbon monoxide are known to have caused death to people due to asphyxiation. Hence, limiting smoke spread can save the lives of patients in health care facilities.

The basis of passive protection system is to construct sections of the buildings in a compartmentalized form. The integrity of the system is lost if openings in floors and walls through which electric cables, air ducts, steam or oxygen pipelines run, are not properly sealed. It is vital to seal such openings with a medium which will not allow fire and smoke spread.

A study of major building fires reveals that in most cases, the fire spread was through AC ducting resulting in fire spread to the upper floors. It is, therefore, necessary to provide fire dampers to air ducts of AC systems to segregate areas connected by the duct from an area where fire has started. The application of fire retardant paints on bare wooden surfaces can delay/ minimize fire spread and illustrates another form of fire protection.

Maintenance: Competent persons should be responsible for the care and maintenance of fire protection systems. All inspections should be recorded in a register and reviewed by a competent person.

Regular inspections of emergency exits, public address system, fire pumps etc should be made by responsible persons.

Evacuation

In health care units, evacuation becomes an uphill task due to the condition of the patients who are not in a position to move freely like others. Panic that one may be cut off also makes the situation more difficult.

Dividing the individual floors into smaller areas in health care units should be considered. This is essential from the life safety point of view and will help in moving patients, thereby giving a greater flexibility.

The fire alarm system should also be designed to augment the evacuation strategy. This means that fire alarm zones will be smaller than in other types of premises. National Building codes may be referred for guidelines.

Emergency Management

Actions during disasters in health care units are very important and due to the liabilities associated with disasters, a well drawn up emergency management plan is essential.

An emergency may require health care facility staff to respond in ways totally different from his training, basic personality and experience. For example, a nurse may have to decide which of the patients to save in a fire situation as it may not be possible to evacuate all patients at the same time.

Knowing what to do in an emergency is possible only when people attend regular training programmes and are knowledgeable about use of emergency equipment. All employees must be trained in emergency procedure, especially people working in late night or early morning shifts when there are fewer employees. Evacuation strategies should be properly drawn out and explained to concerned employees. Mock drills at frequent intervals are a must.

Training programmes must provide effective results in reducing the fatalities in health care units. The programmes should not only include emergency preparedness to improve staff response, but also give an opportunity to them to identify fire loss prevention concepts. Emphasis should be laid on controlling smoking in patients’ rooms, since the predominant source of ignition in fatal fires is smoking materials. The use of portable fire extinguishers during the incipient stage of a fire should also be part of the training schedule. It is very important to have a good liaison with State Fire Service Department and other agencies.

Conclusion

A hospital fire can be a terrifying experience, sick and immobile patients depend on others to prevent fires and handle emergencies. All employees and those connected with the management o f hospitals/health care centers must assume full responsibility for helping to establish a fire safe environment. Emphasis should be on reduction, control and elimination of factors that contribute to high risk fire situations.

Posted: Dec 20, 2010