Introduction
Hospitals, including intensive care units (ICUs), can be subject to threat from fire and require urgent evacuation.Reference Löfqvist, Oskarsson, Brändström, Vuorio and Haney 1 Emergency evacuation of patients from large hospitals is an (enormous) logistical challenge. Hospital fires occur frequently enough that fire response planning is considered an essential part of hospital organizational safety. Hospital fires requiring evacuation responses occur in both wealthy nations as well as in less developed countries. Assessment of hospital fire events has confirmed the need to improve fire prevention and safety in hospitals.Reference Rispoli, Iannuzzi, De Robertis, Piazza, Servillo and Tufano 2 - 4
To achieve fire safety improvement in hospital systems, it is necessary to understand that hospitals as organizations are complex systems.Reference Chowdhury 5 - Reference Meyer, Pascucci and Murphy 7 In complex hospital systems, fire safety may be perceived as part of the system of safety management for the whole organization, though the responses to a threat to safety (such as fire) probably need their own planned structure in order to be coherent and functional.Reference Karemere, Ribesse, Marchal and Macq 8 Fire safety may be implemented in a general structure of fire safety planning and training, though this type of general structure man not recognize special needs related to different departments in hospital. Alternatively, in some areas of hospitals, fire safety subsystems are needed, and this means that special departments must create special protocols. If a system approach is accepted as a starting point for fire prevention, this must take into account complex interactions in hospital systems, including both human factors and technical details, which may comprise challenges to fire safety.Reference Beard 9 Published experience concerning urgent hospital evacuation shows that specific planning and preparation can lead to a better patient and employee evacuation process.Reference Beer and Santon-Reys 10 - Reference Wapling, Heggie, Murray, Bagaria and Philpott 12
Managing ICU patients in the event of an evacuation is a particular challenge, especially considering that they may need continuous support for vital organ dysfunction, such as ventilator treatment including oxygen,Reference Schultz, Koenig and Lewis 13 or continuing vasoactive support for circulatory insufficiency. Maintaining patient safety in such extreme conditions requires forethought and repeated training. Patients connected to other complex machines and treatments, such as hemodialysis or hemofiltration, require much attention and time before they can be acutely and safely evacuated from their treatment area.Reference Kiekkas, Aretha, Panteli, Baltopoulos and Filos 14 Vertical evacuation, or evacuations to different hospital floors, presents a specific challenge in this context.Reference Murphy and Foot 15 Intensive care patient evacuation can become necessary, even due to smoke or gas when there is not confirmed fire, which presents similar issues.Reference Gildea and Etengoff 16 Provision of care to critically ill patients outside of the ICU presents a risk to patient safety compared to care provided in the appropriately staffed and equipped tertiary ICU, in part due to limitation in access to staff. Misadventures or threats to patient well-being are recognized to be common, even during planned intensive care transports.Reference Carey 17
In order for an ICU evacuation process to function well, the staff must be familiar with both the concepts and the practice. Intensive care units are typically staffed by large groups of employees, some with much experience in their local unit, and others with limited local experience and training. Staff needs to be familiar with fire and evacuation procedures before an event occurs. Preparedness among ICU staff, where there is significant staff turnover, is a challenge. These are the system factors identified as critical for fire preparedness training in the study question.
The fire response leader for the hospital may choose to involve individual department staff in review of the organizational documents, visits, and even training. The extent to which a hospital high-dependency unit, such as an ICU, participates in these planning, review, and exercise sessions may vary between hospitals. Individual ICUs may have a written, specific, local fire response plan, and may include review of these along with patient evacuation exercises (full-scale or mock) as part of their ICU staff training. In the event that staff are familiar with the ICU fire response, and exercises are performed by the unit at some interval, the exercises may be planned and open or unannounced. This type of evacuation exercise, when it occurs, may involve moving actual patients and on-duty staff, or in other facsimile forms. New staff require indoctrination for ICU routines for staff in the event of fire and evacuation. When this indoctrination, and even renewed training, occurs may vary from department to department.
With these system factors in mind, the overall study goal was to assess the current preparedness for ICU evacuation for fire in all hospitals which are part of the national public health care system in a wealthy country, using Sweden as model. The hypothesis was that the current level of preparedness for ICU fire evacuation in the national public hospital system in a wealthy country was high. The hypothesis was examined through analysis of written questionnaire responses from the national cohort of managers of ICUs in the study country.
Methods
Ethical approval for this prospective questionnaire-based study was provided by Committee for Ethical Vetting of Human Research in Umeå, Sweden (dnr 2013-210-31). Swedish ICUs were identified as those which currently care for ventilator-dependent, acutely ill patients. Subjects were individuals administratively responsible in their ICU for disaster preparedness in all 84 Swedish ICUs. Neonatal ICUs and other high-intensity care areas where there is no respirator support were excluded.
This questionnaire was adapted and developed from an earlier report.Reference Kiekkas, Aretha, Panteli, Baltopoulos and Filos 14 The questionnaire (Supplemental File 1, English version; available online only) included 42 questions which had specific yes or no (or do not know) answers. The questions were translated to Swedish, amended and adapted to Swedish circumstances, and then reverse translated back to English in order to confirm language validity. The questionnaire was further modified in some places, in collaboration with the Swedish Fire-Rescue authority, in order to address Swedish conditions and terminology (Supplemental File 2, actual Swedish questionnaire text; available online only).
Leaders in all the ICUs at each hospital were identified, received an explanation of the study, and an invitation through their work electronic mail to voluntarily participate anonymously using a web-based questionnaire. If they did not respond, they received up to two reminder emails. All responders received a follow-up telephone call from one of the investigators where they could ask questions and reform their responses if they wished. Responses were de-identified and collected.
The main outcome variables included presence of a disaster plan, the presence of a fire preparedness and ICU evacuation that involves not only where employees should go, but also a plan for practical prioritization, as well as planning for further care at an evacuation point. Further main outcome variables included reporting of specific annual fire evacuation education or training, both for temporary and permanent employees. Secondary parameters included those concerning details of logistics involved in preparation, education, training, evacuation practice, and more.
Questionnaire responses were collated onto a single computerized spreadsheet and then further analyzed using SPSS (SPSS 22, IBM Corporation; Armonk, New York USA). Frequencies and percentages of responses are presented for the number that responded to the specific question. Where the person answering the questionnaire left no response, missing responses were not included in the reported frequencies in the Results text, though these are provided in the Supplementary Table 1 (available online only).
Results
General Responses, Evacuation Plan
There was an invitation to 84 ICUs, to the Department head and person responsible for fire response preparation. A completed questionnaire response was received from 75 ICUs, giving a response rate of 89%. All hospitals, or 74/74 (100%), reported having a hospital fire evacuation plan, 66/73 (90%) responses reported having a formal ICU-specific fire evacuation plan, while 7/73 (10%) reported that they did not have an ICU-specific fire evacuation plan.
ICU Patient Evacuation Training/Education and Experience
Additionally, 70/74 (95%) reported having some form of recurring fire evacuation training/education for their permanent ICU employees, while 4/74 (5%) reported that they did not have this. The timing and frequency of these training/education sessions, as well as what was included in the sessions, varied among responders (Supplemental Table 1; available online only). Only 14/65 (22%) responders reported that there were obligatory training/education sessions for fire evacuation for temporary employees, while 51/65 (79%) reported that they did not have this. Practical exercises of any scale to practice evacuation were reported to have occurred at least once by 14/74 (19%), while 60/74 (81%) reported never having practiced patient evacuation. Of these evacuation exercises, 11/14 (79%) reported that these were conducted together with their local Fire and Rescue services. Very few reported experience with an actual ICU evacuation (practice or otherwise) which included patients 3/74 (4%).
Evacuation Planning
The number of ICUs reporting that there were multiple pre-determined fire isolation areas first outside of their ICU was 27/75 (36%), as a pre-determined place where the personnel should take their patient. In the event of need for evacuation/patient relocation within the ICU, 54/68 (79%) reported a specific nearby fire-protected zone for employees and patients within or directly connected to the ICU.
As far as details of evacuation planning outside of the ICU, vertical evacuation of patients was planned with an elevator for 14/71 (20%) and by stairs for 31/72 (43%). Concerning evacuation plans for individual or specific patients, 4/75 (5%) responded that personnel systematically prepare an emergency transport checklist for each individual patient and their necessary medical items. In the event of patient evacuation from the ICU, 19/49 (39%) reported that there was a pre-arranged agreement with a neighboring hospital to accept patients. During evacuation, specific plans for sensitive patient care materials (ie, sedatives and vasoactive drugs) availability outside of the ICU was reported for 37/73 (51%), and there was no specific plan for this for 36/73 (49%).
Prioritization for Evacuation Process
Concerning patient prioritizing during fire and ICU evacuation, only 25/63 (40%) of ICUs reported that a written policy of this type was available in their ICU or hospital, while 38/63 (60%) did not. Many different factors were noted in the text responses as most important when prioritizing which patients to move first (Supplementary Table 1; available online only).
If a hospital fire spreads so that the ICU must be evacuated, it was reported that, in their policy, the person that makes this decision was the following: fire chief 6/75 (8%), ICU physician in charge 20/75 (27%), ICU nurse in charge 11/75 (15%), ICU physician and nurse together 20/75 (27%), and other categories reported in lower frequencies. A specific instruction for turning off the local ICU oxygen delivery during suspected fire was present in the fire response plan for 49/75 (65%) of ICUs.
Discussion
The main findings showed that most ICUs had a unit-specific, written fire evacuation plan, an intention to perform introductory training to new or temporary employees, as well as an intention to perform annual training and practical exercises. At the same time, the majority of the responding ICUs reported that they did not consistently perform this education and annual training. Very few had ever participated in an ICU evacuation, in practice or in a real situation. These results were unexpected and demonstrate less preparedness (in this form) in these responses compared to reports from a country where there have been several recent, well-publicized hospital fires with evacuations.Reference Löfqvist, Oskarsson, Brändström, Vuorio and Haney 1 , Reference Sánchez-Palacios, Lorenzo Torrent, Santana-Cabrera, Martín García, Campos and Carrasco de Miguel 11 , Reference Kiekkas, Aretha, Panteli, Baltopoulos and Filos 14 One interpretation of this is that there can be complacency. In the country where this survey was conducted, there has not been a hospital fire with ICU evacuation within the last 15 years. Given that these fire preparedness plans all call for annual training, then this can also be seen as a matter of local noncompliance.
One can argue that optimal preparation for ICU patient care and evacuation in the event of fire would be based on successfully managing and executing four distinct aspects: (1) leadership structure, planning, and equipping according to plan; (2) personnel education and training; (3) evacuation-necessary resources (personnel and equipment/drugs); and (4) provision for good care of patients after evacuation. To accomplish these, the value of systematic training has been demonstrated.Reference Kiekkas, Aretha, Panteli, Baltopoulos and Filos 14 This knowledge clearly has not been well disseminated.
One interpretation of these findings is that they indicate that there can be a degree of complacency in the hospital organizations and departments concerning risk for patient and personnel injury from workplace fire in hospitals. Another aspect is that there may be a general perception of risk for fire in the workplace is low based on modern hospital design (for example, no stoves/ovens in many new clinical departments). Even if the risk of fire in or near the ICU is low, the risk of smoke and inhalational injury is higher related to fire anywhere in the hospital buildings.Reference Gildea and Etengoff 16 Reports of the results of training on observed responsesReference Sánchez-Palacios, Lorenzo Torrent, Santana-Cabrera, Martín García, Campos and Carrasco de Miguel 11 , Reference Kiekkas, Aretha, Panteli, Baltopoulos and Filos 14 suggest that the type of complacency for this issue that was observed in one country probably is quite dangerous.
Several practical steps might be useful in improving fire and evacuation preparedness for individual hospitals and ICUs. The first step is recognizing one’s own degree of preparedness or lack of preparedness. Instituting preparedness training sessions and evacuation exercises in an ICU are a matter of recognizing the issue and then prioritizing workplace resources. All responders in the survey stated (in direct verbal contact/follow-up with all ICUs) that this issue of ICU fire and evacuation preparedness with annual training was for them well-recognized and an established part of the departmental work plan, despite the fact that a large portion of departments did not actually put this into practice.
Even though most ICUs responding in this survey had departmental-specific fire response plans, many of these departments were reported to have plans that lacked detail concerning practical aspects of patient evacuation. Leaders in ICU departments need to critically assess their existing plans to identify whether or not they have a practical and detailed plan for ICU patient evacuation. Where adequate plans (preparation, operational direction for evacuation procedures, and prioritization) are missing, this needs to be corrected. Practical details are needed for prioritizing patients and activities: which patients go first and where, and with which personnel, as well as logistical preparation for patients with advanced needs (drugs, ventilator/oxygen, or monitoring). Without this type of leadership document and guidance available in a department, it is difficult for personnel to understand how they could practice any form of disaster response, plan-based, ICU evacuation training.
Limitations
Perhaps the most important factors leading to the limiting departmental preparedness that was observed are personnel beliefs and attitudes. Some perceived beliefs and attitudes (reported anecdotally in telephone follow-up of the questionnaire) can be summarized by the following: belief that one’s own modern hospital could never have a fire; belief that a Fire and Rescue service, which is only a few short minutes away, will be a complete solution in the case of fire; disbelief that evacuation of ICU patients is possible and practical; shifting responsibility to others, belief that “I” will not need to be part of the solution; perception that patient-care workload will not permit time for these kinds of courses and exercises; and belief that if the evacuation guidelines were more detailed and specific (for the ICU), then personnel could actually practice them.
Evacuation plans need to be adapted to how people tend to behave in threatening situations. Similarly, what people do during an event (or people in the department when an evacuation alarm is activated) is presumed to be, to some extent, influenced by how well they have trained.Reference Kiekkas, Aretha, Panteli, Baltopoulos and Filos 14 It is known that even among highly trained personnel, there is a tendency for many to act without further reflection, move out of the alarm area and out of the building or work location when there is a confirmed fire alarm, as has been observed in on-ship fire events.Reference Jarden and Quirke 18
The main limitation of this study design is the indirect reporting of departmental preparedness by the persons departmentally responsible for this, rather than direct examination of the actual plans and practices by an investigator. One risk is over-reporting of departmental preparedness, as there is less likelihood of under-reporting. It is possible that some details were lost or confused by subjects in the process of filling out the questionnaire, which contained many questions. The survey was limited to departments characterized by general ICU adult populations, though the same issues are relevant for more specialized units (ie, possibly neonatal, post-operative units, dialysis, infectious disease ward, hematology/protective isolation patients, and more) which tend to be smaller in bed number and have smaller personnel groups.
Conclusion
This questionnaire-based assessment of ICU fire preparedness in the national public health care system in a wealthy country showed an unexpectedly low level of fire preparedness in the ICUs. This lack of preparedness was manifest particularly as lack of implementation of local specific plans, personnel education, and training for ICU evacuation in the event of a fire threat. In conclusion, even where national requirements exist for evacuation planning, education, training, and regular exercises, these may not be locally implemented, or may be implemented only in part. Lack of actual evacuation exercises seems to be the most common missing activity. Excellence, even in fire and evacuation response, needs to be a high-priority in ICUs in order to reduce ICU patient risks in the event of hospital fire.
Supplementary Material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1049023X17000152
