Introduction (Updated 20 January 2022)
Since the outbreak of the pandemic in March 2020, at least 60 (as of 11 November 2021) incidents of hospital fires associated with intense oxygen use have been found to have occurred in various countries around the world, causing the deaths of nearly 400 people and injuring many more. The majority of the dead and injured were patients extremely ill with the novel Coronavirus and others were their health care providers. Most deaths resulted directly from the fire but there were also several deaths from patients deprived of oxygen as a result of the fire, although in many cases, no exact numbers of these indirect deaths are available. (An additional incident was responsible for an estimated 36 deaths where a pipe failure depleted the oxygen supply but did not result in fire.) A review of past incidents reported in the global media indicates that the number of events since March 2020 far exceeds the number of similar occurrences in any prior given year.
This special issue of the Lessons Learned Bulletin (LLB) is intended to raise awareness of risks associated with oxygen-rich environments in hospitals due to intensified use of oxygen therapy. The pandemic has created a high reliance on providing supplemental oxygen to extremely ill patients to combat severe effects of the disease. It is important for hospitals to be fully prepared for the elevated risk of fire associated with oxygen-rich environments, particularly in intensive care units where several oxygen ventilation units may be in operation.
The contributions of Mark Hailwood to this special issue are greatly appreciated.
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Most recently, on 25 April 2021, a fire in a Baghdad hospital treating Covid-19 patients purportedly started when an oxygen tank failed in storage, resulted in the deaths of at least 82 people (some from the fire and some from the lack of oxygen) and injury to over 100 others. According to a government spokesperson, there were no smoke detectors, sprinkler systems or fire hoses, and the fire spread even more quickly because of flammable material used in false ceilings in the intensive care ward. Only the day before, on 24 April 2021, 13 people died in a fire that started in the intensive care unit (ICU) of a Covid-19 hospital near Mumbai, India.
These events followed numerous other tragic events, including a fire involving a high flow oxygen ventilation device on 19 December 2020 that killed 10 Covid-19 patients in a hospital ICU in Gaziantep, Turkey. A similar fire in a hospital ICU killed 10 people in Peatra Niamt, Romania, in November 2020 (see below). JRC research shows that there have been at least 20 incidents of fires caused by oxygen-rich environments in hospitals reported in the media in 2020, most of them in hospital intensive care units. Of these, 8 resulted in multiple fatalities. Although many hospitals successfully responded to such incidents and avoided injury, most events still required evacuation of staff and severely ill patients, while at the same time depriving oxygen ventilation to those in critical condition for the duration of the event.
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Fire in a hospital Covid-19 ward, Piatra Neamț Romania
On 14 November 2020, a fire broke out in the COVID-19 unit of the Piatra Neamț Emergency Hospital, killing ten people, all of whom were patients receiving treatment for Covid-19. Another four people were injured, including two doctors. Authorities have indicated that the fire most likely started with a short circuit in electrical equipment, probably a mechanical fan. The fire was believed to have spread quickly due to the high level of oxygen in the room that was used to intubate patients.
Source: Gheorghita, M., A. Grancea and C. Hogea, 2020, Investigation report of the fire of 14.11.2020, at the Piatra Neamț County Emergency Hospital. Commission of Inquiry. Neamt County, Romania.
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Electrical malfunction causes fire in intensive care unit, Alexandria, Egypt
A fire at a private hospital in Alexandria, Egypt, on 29 June, 2020, caused the death of seven Covid-19 patients. The blaze was reportedly caused by an electrical malfunction in one of the air conditioning generators in the intensive care unit, according to the hospital. Nine hospital staff were also injured. The staff made immediate efforts to put out the fire but apparently they were surprised by the extent and escalation of the flames, a typical sign of a fire fueled by high levels of oxygen.
Source: https://masralarabia.net/ Item 1546692 (30/06/2020) and various other media sources
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Risks associated with oxygen-rich environments
Oxygen is essential to life and generally makes up about 21% of the gases in the air we breathe. Many users may not be aware of hazards associated with oxygen-enriched atmospheres. However, chemists and process safety specialists recognize its hazardous aspects in relation to its contribution to corrosion and its role in chemical reactions. Pure oxygen reacts with common materials such as oil and grease to cause fires, and even explosions, when released at high pressures. A leaking valve or hose, and openings at interfaces of masks and tubes, when in a confined space or where air circulation is low, can quickly increase the oxygen concentration to a dangerous level. Even a small increase in the oxygen level in the air to 24% can create a fire hazard. In an oxygen-enriched environment, materials become easier to ignite and fires will burn hotter and more fiercely than in normal air. There is also a potentially heightened risk of using ethanol-based and organic solvents as cleaning agents in oxygen rich atmospheres. Ignition can come from gas velocity, friction, adiabatic heat, and contamination, and can be generated by the oxygen devices themselves (through improper handling or design) but also by the external environment.
Notably, six incidents of fires in Covid ICUs have been reported as attributable to electrical faults and some reports have quoted witnesses as being overwhelmed very quickly by the rapid spread of the fire. The ease of ignition and rapid escalation are typical signs that an oxygen-rich atmosphere is involved.
The rising incidence of fires in Covid-19 hospitals
Fires involving medical oxygen are not a new phenomenon but are more common in the operating theatre where oxygen is routinely administered. In these settings, strict safety protocols are normally enforced and surgical staff are well trained in dealing with oxygen hazards. Moreover, they involve only one oxygen ventilation unit and the oxygen-rich environment is concentrated around the face of the patient.
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However, recently, the Covid-19 pandemic has necessitated increasing oxygen ventilators available in intensive care units. This has led to an increased electrical demand in the ICU, which in some cases may have overloaded the electrical supply systems. It has also meant that, due to the increased number of oxygen ventilators, that the oxygen concentration is more readily elevated. Given that infectious units have a low air exchange rate with the outside environment by design, the potential for a dangerous oxygen rich environment is increased. While the most deadly fires have been associated with intensive care units, there have also been at least two incidents of fires in storage rooms where oxygen tanks are held. In one case, more than 150 patients were evacuated from a dormitory that was being used as a temporary coronavirus hospital in Chelyabinsk, Russia, on 31 October 2020 because of a fire in the oxygen storage room that spread to the rest of the building. (Source: https://www.reuters.com/article/us-health-coronavirus-russia-fire-idUSKBN27G0H1). An increased use of oxygen can create elevated risk in the oxygen delivery system and storage locations if conditions and practices are not well-suited to meet the higher demand.
Preventing and preparing for oxygen-induced hospital fires
The JRC is currently working on recommendations for applying more rigorous risk management approaches. In particular, it will recommend borrowing strategies developed for chemical process safety to manage flammable and explosive atmospheres, so-called ATEX environments, so that there is no possibility of ignition when such hazards are present. Management procedures need to involve the whole of the management chain including not only medical and nursing staff, but also housekeeping, cleaning, electrical maintenance and other technical departments. Furthermore, emergency preparedness should take into account potential intensive care unit fires, incorporating necessary measures for reducing impacts including response equipment, training of staff, and planning for the practical and psychological needs of recovery.
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Recommendations for reducing risks of oxygen-related fires in Covid-19 treatment centres (Updated 27 April 2021)
- Short circuits and failure of the electrical system are the most common initiator of oxygen-related fires in ICUs. Electrical capacity needs to be evaluated before increasing oxygen therapy intensity to ensure that it is sufficient. Otherwise, the electrical infrastructure can overheat and start a fire.
- All electrical equipment, including ventilators, in oxygen hazards zones has to be maintained to the highest standards.
If these recommendations are challenging in the short-term for some hospitals with the urgency of Covid-19, they still can do the following:
- Fire risk associated with oxygen therapy should be overseen at the highest levels of hospital management, and involve all health care, administrative, and maintenance staff.
- The hospital administration should recognise that an increase in oxygen ventilation therapy is a significant change that can elevate fire risk substantially. As such, it should trigger an evaluation of the elevated risk, a prevention and control strategy, and communication to all relevant staff. It generally affects all ICUs or Covid wards, the oxygen ventilation equipment, the electrical system the air circulation, the oxygen supply system, and its storage.
- Those involved in storage, distribution systems and handling of oxygen tanks, need to be trained on oxygen hazards and how to recognise dangerous situations that could lead to oxygen leaks and fires.
- Even in Covid-19 wards, ventilation needs to assured so that can help reduce oxygen concentrations. There are techniques that can be used that do not spread infection to other parts of the hospital.
- Flammable materials and substances should not be used, or should be used sparingly and with great care, in oxygen hazard zones.
And in the future ...
- Guidance and training on prevention and risk management strategies need to be developed and standardised for oxygen hazards in all parts of the hospital, but especially ICUs, oxygen distribution systems, and storage. This information should be widely available and become part of training of health care workers and hospital administrators, as well as their education institutions.
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Useful links (Updated 27 April 2021)
- Guidelines for reducing oxygen-related fire risk in hospital intensive care unitsUK National Health Service (NHS) Fire Risk Assessment (FRA): Guidance on completing specific FRA for temporary wards provided for Covid-19 treatment or care (includes checklist) (published April 2020) https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0131-covid-19-estates-facilities-fire-risk-assessment.pdf
Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS), 2019, Guidelines for the provision of intensive care services, 2nd edition, June 2019, https://www.ficm.ac.uk/sites/default/files/gpics-v2.pdf, pp. 177-180
- Yartsev, A, 2017, Fire safety in the ICU, Deranged Physiology, A free online resource for intensive care medicine, https://derangedphysiology.com/main/required-reading/administration-and-data-management/Chapter%205.1.1/fire-safety-icu#:~:text=Protect%20the%20patients%20in%20immediate,Limit%20the%20damage%20to%20property
- Messer Group, Safety alert: Hazard of oxygen-enriched atmosphereds in healthcare facilities, https://corporate.messergroup.com/safety-alert-hazard-of-oxygen-enriched-atmospheres
Surrey County Council - Surrey Fire and Rescue Service (SFRS), Fire Safety during COVID-19, https://www.surreycc.gov.uk/people-and-community/fire-and-rescue/businesses/responsibility/covid-19
General guidance on management of oxygen hazards
Lessons learned from oxygen-related accidents in intensive care units
- Chowdhury, K., 2013, Fires in Indian hospitals: root cause analysis andrecommendations for their prevention, Journal of Clinical Anesthesia, Volume 26, Issue 5, August 2014, Pages 414-424, https://doi.org/10.1016/j.jclinane.2013.12.014
- Dhaliwal, N., R. S. Bhogal, A.Kumar, and A. K. Gupta, Responding to fire in an intensive care unit: Management and lessons learned, World Journal of Emergency Medicine, 2018; 9(2): 154–156, doi:5847/wjem.j.1920-8642.2018.02.014
- Kelly, F. E., Rowan Hardy, Tim M Cook, Jerry P Nolan, Tim Craft, Mike Osborn, Cindi Bedor, Julian Hunt, 2014, Managing the Aftermath of a Fire on Intensive Care Caused by an Oxygen Cylinder, Journal of the Intensive Care Society, https://doi.org/10.1177/175114371401500404
Sankaran, K., A Roles, and G Kasian, 1991, Fire in an intensive care unit: causes and strategies for prevention CMAJ, 1991 August 15, 145(4): 313–315, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1335634/pdf/cmaj00245-0035.pdf
Murphy, G. R. F. and C. Foot, 2011, ICU fire evacuation preparedness in London: A cross-sectional study, British Journal of Anaesthesia 106 (5): 695–8 (2011), Advance Access publication 16 March 2011, doi:10.1093/bja/aer033, https://pubmed.ncbi.nlm.nih.gov/21414979/
Options for hospital ward ventilation
- Fernandes Santos, A., P. Dinis Gaspar, A. Hamandosh, E. Barbosa de Aguiar, A. C. Guerra Filho, and H. J. Lopes de Souza, 2020, Best Practices on HVAC Design to Minimize the Risk of COVID-19 Infection within Indoor Environments, Brazilian Archives of Biology and Technology, Vol. 63, ISSN 1678-4324, http://dx.doi.org/10.1590/1678-4324-2020200335
Risk assessment of oxygen-related risks in hospitals
- Karim, M. Z., L. T. T. Thao, M. T. N. Hanh, N. Q. Dung, N. T. Anh, and K. R. Alam, 2016, Medical gas safety management: Evidence based risk intervention study of HMA gold award project at Vietnamese hospital, International Journal of Science and Research (IJSR), ISSN: 2319-7064, 7(11):1499-1505
Corporate governance for high hazard situations
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