ICU planning for fire safety : More you sweat behind planning, less you bleed during a disaster.

Fires in hospitals and ICUs are not rare.

In 2017, India saw 16 lakh incidents of fire (around 18 per cent of the world-wide tally) with over 27,000 deaths. Indian casualty figures were 2.5 times that of China. Every 5th fire death in the world is in India. India recorded 1.6 million fires and 27,027 deaths, according to a 195-nation analysis by Global Diseases Burden published in The BMJ Injury Prevention journal recently.

Why ICUs are most vulnerable

A higher percentage of oxygen in the air, due to oxygen lines, portable oxygen cylinders, and oxygen delivery
A higher percentage of vulnerable patients who are critical or cannot walk on their own, during a fire hazard
A lot of enclosed areas due to infection control and other protocols, because of which smoke remains trapped inside, suffocating people and killing them.
Heavy use of electrical power, cabling, sockets and equipment
Heavy use of Bio-medical equipment having fluctuating electrical loads, and numerous electrical connections
Oxygen lines, and oxygen bottles that act as a catalyst for fire explosions
Highly combustible materials and alcohol-based liquids such as sanitizers, cleaners, disinfectants, etc
High patient density per sq ft, especially in critical care areas like ICU, HDU, responsible for higher mortality rates, and injuries
Massive storage of materials such as linen, medicines, various packaging

To summarise, ICU has comparatively more vulnerable people, materials that act as fuel, an ample amount of pure oxygen supply, in confined spaces, which if not planned and stored correctly can result in disaster.

ICU planning for fire safety :

Electrical Elements

“Most of the hospital fires in India are related to electrical short circuits.” As a planning and design consultant for hospitals, I advise my clients to :

Keep an experienced electrical engineer as part of the consultant team.
Plan according to a maximum electrical load, assuming hospital/ICU running at full capacity
Use fireproof electrical cables in and around the ICU area.
Use fireproof electrical cables used by AHU vendors, in their panels.
Use fireproof Cat 5 cables and fireproof other low voltage cables.
Use fireproof sockets, and prevent loose sockets.
Use enough permanent sockets to avoid external sockets and extension boxes.
Maintain parallel double back up of UPS and generator using a load switch
Take precautions to prevent load fluctuations and static.
Maintain proper earthing of all-electric sources and also equipment
Use fireproof overhead panels.
Keep Oxygen lines and electric sockets at two extreme ends, as far as possible.
Keep Oxygen lines and biomedical equipment as far as possible.
Use two separate overhead panels, one for medical gas, oxygen line and suction, and an independent panel for electrical and electronic wires.
Use under-table sockets for computers for nursing inside the ICU.
Use Integrated CPU monitors inside ICU, to avoid less electric connections and static.
Have monthly socket and cable checking ( Electric audit )
Have Separate electrical connections for critical care biomedical equipment and non-critical care equipment, so that in the event of short circuit or fire, the non-critical care power supply is shut off.
Keep electrical central panels and controls outside of the ICU area.
Implement coding of electrical wires
Make electrical layouts easily accessible to the ICU staff.
Avoid using multiple plugs in a single socket, as it can overload the outlet.
Use appropriate voltage stabilizer to manage fluctuating loads of Ventilators and other equipment.
Keep washbasins away from computer panels and electrical sockets at the nursing station.
Avoid usage of personal devices and its charging inside the ICU area.

When asked, Mr Manish Patel, the Director of Cyber ( Experts in fire fighting systems and low voltage Systems Integration ), he was kind enough to provide his input on cabling and fire fighting.
“Cables and short circuits are a major source of the fire. We should use FRLS, LSZH and fire survival cables that help to hold fire or produce less smoke which are the main reasons for injuries or deaths through suffocation rather than burns. Hence, these cables are highly effective.” (Mr Manish Patel, Director, Cyber)

Medical gas, oxygen and vacuum systems

Oxygen (O2) enrichment of air, is primarily responsible for most of the fires, particularly in intensive care units. Larger proportion of oxygen in air can be partly managed by effective use of AHU ( Air Handling Units ). Every air cycle through AHU brings in 10% external air, which partly reduces the extra oxygen content within ICU.
As discussed above in the Electrical elements section, make sure that oxygen and medical gas pipelines are away from Ventilators and other biomedical equipment which use electricity and can produce heating or sparks.
Make sure there are systems in place which can detect leakages in oxygen and medical pipes.
Most ICUs carry portable oxygen cylinders also, which can explode in some types of fire situations, and therefore make a provision for special fireproof storage cabinets, to store portable oxygen cylinders.
Make a provision for main valves for different areas. For example, the main valve for medical gas and oxygen lines, outside ICU, can be turned off in case of fire inside ICU, depending on the situation.
Do not turn on oxygen cylinders inside the ICU. Test the oxygen cylinders outside the ICU area, connect the tubing and oxygen delivery device, and then bring it nearer to the patient in the ICU. Below is an eye-opener case study of the ICU fire, which happened in U.K hospital.

Furniture and interior materials

While planning an ICU area, my team and I create a fire-resistance comparison sheet to avoid the use of combustible materials in the ICU area, at the same time I ensure that this does not compromise the aesthetics or functionality. It is a good idea to create a materials sheet with their fire resistance or combustion ratings.

Here are a few things that can help you make your current or future ICU safer:

Instead of using combustible Thermocol panels, use gypsum fall ceiling, if you are planning to have a fall ceiling.
Do not use any wood material as part of the ICU interior. For nursing stations and aesthetic purposes, if you have to use wood, then you can use fireproof plywood.
Use fire-resistant or fire-retardant medical curtains, mattresses, bedding materials, and linen.
Avoid using materials that can create toxic smoke on burning.
Use airtight metal storage cabinets or glass cabinets in ICU for storing Alcohol-based liquids and other combustible materials.

You will find a list of flammable and liquids with their flash point and boiling point data below :
https://www.safety.duke.edu/sites/default/files/Section_6_FireSafety.pdf

Air and smoke handling

Did you know, most deaths caused in Hospital fires are due to inhalation of poisonous smoke generated? Toxic smokes like carbon monoxide, hydrogen cyanide, and Phosgene can rapidly make patients unconscious. According to Wikipedia, when people are sleeping, their nose and brain are not able to sense the presence of smoke. It’s only when smoke enters their lungs the body wakes up, which in turn wakes up the brain. Carbon monoxide is the most common toxic smoke generated in fires and is also the most lethal for human beings.

Use fire dampers and suction ducts to remove smoke immediately

Sample Illustration of a Proprietary Ventilation/Smoke Extraction System by Belimo9

Patient evacuation

Patient bed movement across an entire hospital is the key. I highly recommend my clients to plan hospital areas and hospital movement spaces keeping patient bed movement in mind.
Patient evacuation becomes easy if the entire patient bed shifts across all the areas of the hospital. It also eliminates the problem of stretcher shortage at the time of the fire and minimizes patient injuries.
With 45+ hospital planning and design on hand, my team and I always press hard on running a patient bed movement simulation, before and during internal walls are constructed.
Following the infrastructure guidelines of fire authorities, National Building Code, NABH, JCI, and WHO patient safety, will cover most issues related to fire and patient evacuation.

Access to proper fire fighting

Mr Manish Patel, Director at Cyber ( Experts in fire fighting solutions ), and his team were kind enough to prepare a comprehensive brief on Firefighting System Provisions for Hospitals.

This highly informative piece of the document covers most of the details about fire fighting solutions, facts, figures, ratings, and more. I highly recommend downloading this and keep it with you for your future reference. Below is the link to download.
Click here to download comprehensive brief on Firefighting System Provisions for Hospitals

Mr Manish Patel, Director at Cyber

Following international and national patient safety standards of WHO, NABH and JCI

Everyone should remember that every big fire starts from a small one; therefore, nothing should be considered insignificant within hospital premises. The national and international accreditation standards like NABH, JCI, WHO Patient Safety & Friendly Hospital (PSFH) standards focus on the preventive aspects of fire and related disasters. NABH widely takes the NBC (National Building Code) guidelines into consideration while exerting the rules.

Fire escape routes

Accreditation standards mention that the hospital should have a fire escape plan on every floor. Critical areas like ICUs require the plan in the department prominently displayed to identify the evacuation area. Exit doors should be openable and free from any materials which will obstruct the way.

Fire exit signage

The fire exit signage, when appropriately placed, shall act as a saviour in cases of such emergencies. Amidst all the chaos happening in case of fire, the prominently displayed and self-illuminating fire exit signage shall help the people locate the safe exit area, which leads to the assembly point.

Fire detection

The ICUs should have adequate numbers of smoke detectors and fire alarm system. A properly functioning detection system shall quickly detect fire, and the hospital staff shall have sufficient time to act.

Fire fighting system

The ICU should have adequate numbers of fire extinguishers, sprinklers and hydrants to immediately take measures to control and contain the same.

Maintenance of equipment

In most post-event investigations, it has been noticed that the fire fighting and detection equipment are regularly not checked. The preventive maintenance of such equipment is highly essential for the effective functioning of the same during such instances. ICUs being the high-risk area in the hospital, it is essential to check the proper functioning of the equipment frequently. Regular refilling of the fire extinguishers as well as keeping track of the expiry dates should be a top priority.

Bed to Bed distance

According to the guidelines issued by NBC for the ICUs, the minimum bed to bed distance is required to be 6 feet. Apart from the logical explanation related to infection control practices, this distance shall also help to minimise the risk of fire-related disasters. The safe distance ensures that the biomedical equipment, oxygen lines, electrical sockets and such other things are physically apart from each other. In case there is a spark or any such event on one bed, the same will not immediately affect other beds in the ICU, and the staff will have some time to intervene and safeguard other patients.

Deployment of Fire Safety Officer

The hospital should designate a fire safety officer depending upon the size of the hospital. The job responsibility should be clearly communicated to the FSO which includes conducting regular safety checks, keeping track of fire NOC, maintaining operational and maintenance plan of all the fire equipment, training of the staff and conducting regular mock drills.

Conduct Mock fire drills

Training helps the hospital staff learn about the various fire fighting mechanisms. At the same time, Mock drills shall help them to act upon during the disaster situation. It is imperative to conduct at least two mock drills in a year. At least one mock drill should be done in the ICU department to appraise the staff as well keep them ready for facing any fire instance in their department.

Legal Compliance

The leadership should be aware of the applicable laws and regulations related to fire safety. The hospital should have a valid Fire No Objection Certificate (NOC) from the appropriate authorities in their city/state. Ensuring legal compliance will take care of the existing fire norms, which in turn will help prevent any significant fire hazard.