Fire Safety Hazards: How Safe Are Our Hospitals?

Sir,

Globally, every fifth fire-related death in 2017 took place in India.[1] Fire can occur to anyone, at anytime, and at anywhere including health-care facilities. Hospital fires can be devastating in terms of loss of life, injuries to patients/staff, and loss of property/equipment, more so because hospitals house a large number of vulnerable people (old/sick/disabled/pregnant/children, immunecompromised, on life support, and incapable of moving). People losing lives at the altar of cure, is a saddening tragedy leading to several health, economic, and social ramifications. In the recent past, several fire incidents have been reported all over the country, to name a few, at AIIMS – New Delhi, SAL Hospital – Ahmedabad, SMS Hospital – Jaipur, LNJP Hospital – Delhi, North Bengal Medical College and Hospital – Siliguri, Shine Children Hospital and Gandhi Hospital – Hyderabad, SSG Hospital – Vadodara (2019), ESIC Kamgar Hospital – Mumbai, Kakinada Government General Hospital (2018) – Andhra Pradesh, RML Hospital – Farrukhabad, BRD Medical College – Gorakhpur (2017), SSKM Hospital – Kolkata, Medical College Hospital – Murshidabad, GTB Hospital – Delhi, Guntur Government Hospital – Guntur, and SUM Hospital – Bhubaneswar (2016). Some of them involved considerable loss of human life (RML Hospital Farrukhabad and BRD Medical College, Gorakhpur)[23] and therefore drew wide media attention.

Fire-related disasters in hospitals including near- to-miss events, humanmade, or sequel to natural events, are more frequent than assumed and emerge from external or internal threats. External threat is exemplified by a bomb blast in Civil Hospital, Ahmedabad (2005). There were 21 simultaneous bomb blasts in the entire city within 70 min, followed by another bomb blast in the trauma center of Civil Hospital, timed in a way to cause bigger damage when the victims of earlier blasts arrived at the hospital. The affected people included two doctors and several volunteers who gathered to donate blood for the blast victims.[4] Internal threats account for most instances of fires, for example, the accidental fire in a corporation-run public hospital of Ahmedabad (2010),[5] where patients were trapped on the top floor. As the building was centrally air conditioned, there was no channel for the smoke to come out. It was tough even for firefighters to smash the glass windows to let the fumes out. According to some patients, there were no announcements on the public address system and also the staff abandoned them. It was observed that regular fire drills were not conducted and several fire extinguishers were past the expiry date. The 1500-bed GTB Hospital, Delhi, did not have an no-objection certificate (“NOC”) from the fire department.[6] In Odisha too, only four of the 1700 odd hospitals had statutory fire safety clearances.[7] In Nellore, 80%–90% of government hospitals still do not have NOC from the Fire Services Department.[8]

A compilation of 19 events since 2011 found 17 (90%) in government hospitals. Internal errors responsible for the fire accidents were (18/19) due to short-circuit except one which was due to inappropriate use of the hospital basement. Basement, meant for parking, was used as a storehouse for liquefied petroleum gas cylinders, torn mattresses, and wooden boxes. It also housed a pharmacy, a central storeroom, and a biomedical department, all containing inflammable articles. Five hospitals reported repeated event and that too due to the same reason (electric short-circuit). Overloaded electricity point, improper uninterrupted power supply load and acids in the battery, false ceiling panel lined with thermo coal, faulty electric wirings, and overheating leading to burning of wires were some of the causes of electrical fires reported. Safety in health-care institutions is not just a matter of poor planning/regulation but also reflects deeper malaise prevalent in all sectors, including health care, as safety does not necessarily sell.[9]

Most of the short-circuit-related fire gutted the air-conditioning unit in areas such as intensive care unit (ICU) receiving ventilator support, X-ray room, incubator of neonatology unit, pediatric ICU, children's ward, dialysis ward, operation theater, and biomedical equipment's storeroom. Sometimes, these places have equipment such as ventilators with heavy and fluctuating power load, making them vulnerable for short-circuiting. Oxygen enrichment of air is primarily responsible for many fires. The amount of ignition energy needed to initiate fire reduces in the presence of higher O2 concentration and any heat/spark may be the source of ignition. Split air conditioners in ICUs, neonatal ICU, and operating rooms are the source of many such fires, though several other equipment in hospitals have similar vulnerability.[10] In air-conditioned buildings with no natural ventilation, most victims die due to inhaling carbon monoxide from smoke; smoke in the building also hampers rescue efforts.

The electricity load on the day of commissioning a hospital almost doubles from when the facility is designed, and it further goes up nearly 25% annually.[11] No hospital or authority ever estimates correctly, at the time of licensing, the patient load, how many machines it will have, and the required safety checks. The situation is worse in government hospitals where a sheer number of people overwhelm the resources in no time. Over a period of time, minor repairs, haphazard extensions, and replacements might cause some wires to come in contact with each other or create short-circuit, which may cause a very high current flow through wires and cause fire.

Majority of the hospital fires are electrical, caused due to overloading, short-circuit etc., In view of this, the following suggestions can be made:

Intelligent building design to assure hazard prevention, risk mitigation, assurance of life safety, property protection, and continuity of operations and functioning. No hospital building should be put to function unless a building utilization (BU) certificate is obtained from a competent authority. Similar certificates should be obtained for electrical fittings, lifts, etc. Regulations as per the National Building Code should be adhered to and NOC from the concerned Fire Department should be obtained before operationalizing the hospital and should be renewed annually. An effective fire safety program should be in place which addresses and monitors the four important parameters namely means of access through approach roads and open spaces and means of escapes such as external staircases and firefighting equipment. In high-rise hospitals, escape chutes[12] may be installed which ensure rapid and safe shifting of everyone including the bedridden patients

A disaster action plan, including four points based on rescue, alarm, confine, and extinguish, for firefighting procedures with standard operating procedures, should be prepared and prominently displayed with assigned roles to different persons, with their contact details. Regular/periodic training of all the staff and mock drills for rapid safe evacuation should be carried out. An alarm system with a public address system in the hospital to inform everyone about the emergency/disaster must be in place. It may not work in case of electricity failure; hence, it must have a power backup. Suitable linkage with nearby hospital (s) is a must to avoid delay for the treatment of critical patients

A simple solution for electrical accidents leading to fire is to estimate proper load and keeping some buffer before operationalizing, not to make too many changes to the electrical circuiting, and, if any alternation is done, capacity of the wire used should be kept in mind. Indian hospitals need to make several changes in the arrangement of equipment and practice of handling O2 gas, as well as create awareness among hospital staff, doctors, and administrators.

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Conflicts of interest

There are no conflicts of interest.