Definition/Introduction

The Occupational Safety and Health Administration, or OSHA, is the section of the United States Department of Labor that establishes, oversees, and enforces safety within the workplace to minimize the health and safety risks for employees. Additionally, OSHA provides education and outreach to improve employee safety further. OSHA sets general guidelines for all fields but also has subparts that are more specific to high-risk fields like the healthcare field, including but not limited to bloodborne pathogens, harmful chemicals, infectious diseases, and personal protective equipment necessary to prevent exposure to hazardous materials. One such hazard overseen by OSHA is the fire which can cause significant injury or death from direct contact with the flames or, more often, through smoke inhalation.[1]

Fires can be ignited by a wide variety of mechanisms reflected by the array of OSHA guidelines for various sources, including hazardous materials like oxygen and flammable liquids, high-risk industrial trades like welding, high-risk industries like sawmills, and electrical power generation. Once a fire is ignited, the damage can be mitigated by preventing its spread, reflected by OSHA guidelines for emergency action plans and fire protection and prevention.

Regulated specifically under standards 29 CFR 1910 subparts E, H, L, and Q, standards 29 CFR 1926 subparts C and F, and more generally under many others, OSHA aims to establish guidelines for fire safety that are used to prevent the onset of a fire and limit the damage and casualties should a fire ignite. By establishing these guidelines, OSHA can enforce the minimum standards required by a workplace, especially those part of high-risk industries, to ensure optimal safety for employees.

Issues of Concern

With an average of 14 work-related deaths a day, or 5000 per year, in the United States, workplace safety should be of the highest priority for both employers and employees.[2] The number of reported deaths annually, while still extremely high, is significantly reduced relative to before OSHA intervention. The workplace can be hazardous for professionals who commonly work with materials or devices that can be a fire source or combust when exposed to a fire-producing device. This may include but is not limited to open flames, compressed gas, flowing oxygen, welding, surgical electrocautery, electricity, and combustible liquids and gases.

For fires to ignite, three components must be present. The first is a fuel source or something to burn, including clothes and linens, flammable gases and liquids, and human tissues, among other materials. The second is an oxidizer, which will significantly increase the combustibility of the fuel source. Oxidizers include gaseous oxygen and nitrous oxide.[3] Finally, the fire must be ignited by some object which serves as the ignition source. Examples of these objects include various sources of electric current, electrostatic discharge, or heat, such as an open flame. Specific to the medical field, ignition sources may include electrocautery, lasers, defibrillators, and any sort of electrically-charged device. The operating room in a hospital is a particularly high-risk environment as all three components are typically present.[4]

The most significant issue of concern in fires is smoke inhalation. The acute danger of smoke inhalation is the effects that carbon monoxide and cyanide in the smoke may have on the binding capacity of oxygen to red blood cells. Because the affinity of carbon monoxide and cyanide to hemoglobin is higher than oxygen, the presence of these molecules can quickly lead to systemic hypoxia and death. The upper respiratory tract is especially vulnerable to the heat of the fire, given its proximity to the flames. These structures are prone to heat-related tissue injury that initiates an inflammatory cascade with molecules like substance P, calcitonin gene-related peptide, and interleukin-8 to recruit polymorphonuclear cells to potentiate the inflammation further. Therefore, the upper respiratory tract structures become swollen and edematous, which can lead to airway compromise. The lower respiratory tract is less prone to heat injury but more susceptible to direct chemical damage from substances in the smoke such as carbon monoxide, cyanide, formaldehyde, and ammonia. Due to the lower respiratory tract injury, there is greatly increased blood flow to the lungs causing high capillary hydrostatic pressure and subsequent fluid transudation and edema.[5]

The next issue of concern is burning. Scald injuries are the most common cause of burns in children, while open flames are most common in adults. The extent of tissue damage depends on how hot the exposure is and the duration of exposure. The burn will create a different pattern depending on the severity and depth with a central zone of coagulation necrosis, a zone of stasis that can be salvaged with rapid treatment, and a peripheral zone of hyperemia that will recover.[6] The depth of the burn also determines the severity, with superficial burns affecting only the epidermis, partial-thickness burns affecting the epidermis and some of the dermis, and full-thickness burns that affect the entire epidermal and dermal layers and extend into the subcutaneous tissues.[7]

The total percentage of total body surface area affected by a burn is also crucial in determining the outcomes of a patient. More extensive burns that affect greater areas will require more rapid fluid resuscitation and monitoring for electrolyte imbalances due to the flux of fluids.[8] Young males are at the highest risk for work-related burns, which has been attributed to multiple factors, including inexperience on the job, poor enforcement of safety guidelines, inadequate training for handling potentially hazardous materials, and a higher likelihood of being non-compliant with safety guidelines.[9] 

Other considerations include the increasing rate of wildfires that coincide with global climate change.[10][11] These fires are large and unpredictable due to the impact of foliage and winds on their rapid spread. Wildfires also frequently jump locations due to embers floating in the wind and reigniting separately. Rapid evacuation of residents in impacted areas, as well as surrounding areas, is important. Therefore, hospitals in high-risk areas should have evacuation plans in place to transport patients from the hospital to safety in the case of an approaching wildfire.

Considering the issues mentioned above of concern, OSHA has designated a number of requirements for hospitals to follow to ensure the safety of both patients and employees. While OSHA rules are primarily concerned with the wellbeing of workplace employees, the healthcare field is a unique exception in that fire safety rules also protect the patients receiving care from the healthcare facility. In the event of a fire, people must be rapidly evacuated to prevent fire-related casualties, so OSHA has developed many requirements to ensure hospitals have adequate exit routes from anywhere in the building. These include:

1. An adequate number of exits.
2. Exits must open directly outside or to an open area or walkway with direct access to outside. Importantly, these paths must be large enough to accommodate all people inside the building likely to use the exit.
3. Exits must be well lit with appropriate signage indicating the exit route.
4. Exits must be unobstructed and unlocked at all times while employees are present.
5. In the event of construction or repairs, the exits must be unobstructed, and work must not begin until an equally accessible and safe alternative exit is made available.

Other employer requirements for fire safety include the development of both a fire prevention plan and an emergency response plan. These plans must be written and posted within the workplace when the number of employees is over 10. If there are less than ten employees, the plan may be verbalized to the group.

For the fire prevention plan requirement, the written plan must include a list of all major fire hazards, including various materials and chemicals, sources of ignition and how to control these, and the equipment needed to control the fire hazard safely. Also, other aspects of the plan include installing and maintaining safeguards on heat-producing equipment, determining the employees responsible for maintaining equipment for the prevention and control of fires, and the employees responsible for utilizing the equipment necessary to control the fire fuel source.

Specific daily tasks that must be part of the fire prevention plan include general housekeeping to store and clean up flammable materials and wastes, disposal of flammable waste, and cleaning and maintenance of heat-producing equipment. For the emergency response requirement, the plan must include evacuation procedures, procedures for employees that are actively performing rescues and medical duties, procedures to sound the employee fire alarm system, training on the emergency response plan, and reviewing the emergency response plan when an employee is hired, their responsibilities change, or the plan itself is changed.

An important hospital-specific consideration in the emergency response plan is the width of the exits. Standard doors are sufficient exits for most hospital employees, but a hospital bed can only fit through wide doors. Should a fire occur, wide doors would be necessary for evacuating patients who cannot ambulate so their beds can be wheeled through the safety door. 

Additional requirements include providing proper training and safety measures for working with dangerously flammable materials like compressed oxygen, nitrous oxide, combustible liquids, electrical wiring and equipment safety measures, and placement of fire protection systems that include fire hoses, sprinklers, fire detectors, and employee alarms. These requirements are all the minimum requirements set by OSHA, so specific workplaces may exceed them but cannot fail to meet them. Checklists in the operating rooms have been used to identify fire risks and ensure plans are in place to extinguish them efficiently.[12]

While hospital fires are not very common, they can cause large numbers of casualties if fire safety guidelines are not followed.[13][14] Employee preparedness is critical to ensure the safety of the employees themselves and patients in the event of a fire. Quick responses to a fire can help subdue the fire and prevent its spread to other areas of the hospital. The acronym RACE stands for rescue, alarm, confine, and extinguish—this lays out the response employees should have to a localized fire. First, rescuing others is the priority, especially in the healthcare setting when patients may be unable to move, immobilized, or unconscious. Next is to pull the fire alarm to alert the rest of the building and then confine the fire to one location.

Confinement is critically important to isolate the fire and prevent spread to other areas. Finally, extinguishing the fire with a handheld fire extinguisher can be done using the acronym PASS, which stands for pulling the safety pin, aiming at the base of the fire, squeezing the handle, and sweeping from side to side.

Clinical Significance

Fires can cause high numbers of casualties should many people be around the fire and inhale its smoke. Smoke asphyxiation is the biggest health concern associated with fires, and rapid management is crucial for the survival and reduction of long-term sequelae. In the acute phase, the upper respiratory tract edema can quickly close the airway, so monitoring for signs of respiratory distress, shock, poor blood oxygenation, and altered mental status is important to determine if establishing an airway is necessary.[15]

With a secured airway, 100% oxygen is commonly given because of the carbon monoxide poisoning associated with smoke inhalation. Carbon monoxide has a high affinity for hemoglobin, so maximum oxygen concentrations are required to out-compete the carbon monoxide for binding to hemoglobin. This is a crucial step to reduce the long-term neurologic sequelae associated with poor neural tissue oxygenation. For cyanide poisoning, hydroxocobalamin can be used as an antidote. Further management strategies include N-acetylcysteine administration due to the elevated levels of reactive oxygen species that contribute to the pulmonary damage. To address the massive bronchoconstriction associated with smoke asphyxiation, nebulized beta-2 agonists and muscarinic antagonists may be used.

Burn management involves cooling and cleaning the burn. Prophylactic antibiotics are not indicated but could be used in high-risk burns, but dressings with ointments are commonly used to promote healing.[16] After stabilization, the primary goals are to maintain fluid balance, which can be determined by adequate urine output and help prevent secondary organ damage associated with decreased fluid levels.

More extensive burns can greatly increase the metabolic rate in the patient, so proper nutrition is important in the early stages of healing. The damage to the skin compromises the ability of the patient to maintain body temperature homeostasis, so increasing the temperature in the room is important to maintain their body temperature at a normal level to prevent enzymatic and tissue dysfunction and reduce fluid loss to evaporation.

Within the healthcare system, fires involving patients are rare but happen in higher-risk situations like respiratory tract surgeries. These patients are being ventilated with oxygen while under anesthesia during the procedure. The use of an electrocautery device during the surgery completes the triad necessary for a fire—tissue as a fuel source, oxygen as the oxidizer, and cautery as the source of ignition. A handful of reports have been published on this event involving a fire being ignited within the patient's respiratory tract, resulting in tissue damage.[17][18] Additional steps that may be taken to reduce risk are using a fire safety device that utilizes carbon dioxide to prevent fires and has shown great efficacy with up to 100% absolute risk reduction in preliminary trials.[19]

Nursing, Allied Health, and Interprofessional Team Interventions

The major role of the healthcare team in fire safety is promoting prevention strategies. Patients who work in high-risk jobs or have children at home may benefit from fire safety education. A large amount of literature supports the use of education on fire safety to improve patient competency of how to react in the event of a fire and ultimately lead to better outcomes.[20][21][22][23][24] Also involved in this should be community-based education strategies to promote fire safety on a larger scale. Collaboration with local fire departments has proven to be a useful strategy in educating the public on fire safety.[25]

Addressing scenarios that predispose people to injury due to fire should also be addressed. Burnout has been determined to be a significant risk factor for fire-related injury in workers of high-risk professions.[26] The reduced attention to detail can cause catastrophic consequences, so taking proper measures to reduce employee burnout may reduce fire injuries and deaths. Because of the risk of fires within the operating room, changes may also be made to optimize prevention and management strategies which involve surgeons being familiar with the devices being used, the anesthesiologist limiting oxidizer quantities to only the level needed to care for the patient, and the nursing staff and operating room technicians ensuring proper use, upkeep, and storage of the devices is maintained.[27][28]

When a patient presents with injuries from fire, interprofessional collaboration is crucial to optimize patient outcomes. The EMS team will need to quickly evaluate, perform any necessary life-saving resuscitation, and transport the patient to the hospital. Upon arrival, the emergency department team must assess the patient and triage the complications with establishing an airway and improving blood oxygenation taking precedent. The trauma and surgical teams should be consulted depending on the nature and extent of the injuries. The pharmacist should be involved in administering appropriate pharmacology to stabilize the patient.

The burn team may need to be consulted in the event of a skin burn. The nursing staff will be involved throughout the process, especially with patient monitoring and medication administration. After stabilizing the patient, the pulmonologist and dermatology teams may need to consult depending on compromised tissues. Depending on the severity, the patient may need to be transported to the ICU, where the critical care team will take over care.

Other professionals will begin to be involved in the care throughout the recovery phase, such as physical therapy and occupational therapy to rehabilitate the patient. Social work should also be involved to determine the cause of injury and how to prevent another similar scenario. They may also need to support the patient with housing should the fire have taken place at home.

Nursing, Allied Health, and Interprofessional Team Monitoring

Simulation of situations such as fires has proven to be an efficacious way of preparing employees to handle such situations. Therefore, virtual reality devices may be used to simulate fires and prepare staff to respond to fires appropriately.[29] [Level 1]

While OSHA fire safety guidelines are the same between different organizations, carrying out these guidelines may look different at various institutions, so quality improvement projects can play an important role in individualizing an emergency response plan to fires within the operating room.[30] [Level 5]

Community outreach and patient education are also essential to help people prevent and respond to fires. Programs for people at higher risk, or care for people at higher risk, such as children, to experience fire-related injury both improve their knowledge of fire safety and enhance actionable steps taken to prevent fires.[24] [Level 1]

Finally, identifying patients at the highest risk of being harmed by fires, whether it be because of working in a high-risk profession, having little background in fire safety, or living in conditions where fires are more likely, should be performed. Specifically, working with these populations to improve their competency in fire safety may improve outcomes in the event of a fire.[21] [Level 3]

Fire safety cannot be stressed enough, given the high risk of casualty when a fire occurs. Prevention strategies and proper treatment can save lives and improve overall outcomes.