Duty of care

THE OCCUPATION of the Nightingale Hospital. The formation of the vaccination centres. Continuing changes to social distancing/COVID-safe workplaces while maintaining means of escape. Increased oxygen flows within clinical areas and enriched oxygen atmospheres. High fire loading from separation panels. Staffing levels and the evacuation of COVID-positive patients. An inability to enter areas to carry out fire risk assessments and maintenance. These are some of the key challenges we’ve faced in the healthcare world.

While the above list isn’t exhaustive, it serves as a good overview. It must not be forgotten, either, that aside from dealing with the COVID pandemic, the usual day-to-day business of fire safety has necessarily continued.

Back in March last year, it was assessed that there was a real possibility the normal capacity of the NHS could be overwhelmed and especially so in terms of the demand for critical beds. As such, the decision was taken to construct a series of NHS Nightingale Hospitals across the UK. Along with all of the other risks identified from the wider estates world, fire safety was a significant factor in the design and build of these premises. With a tight deadline, in some cases with just nine days for completion, the implementation of fire safety measures represented a significant task.

To be part of a team that was charged with implementing the fire strategy within the NHS Nightingale Hospital Yorkshire and the Humber drew upon all of the experience and knowledge that had come from every conceivable project ever worked on previously. The primary challenge at the Nightingale Hospital in Harrogate, with which I was personally involved, was to incorporate fire safety provisions for the treatment of Level 3 intensive care patients into a conference centre and former supermarket building.

Being involved in the design and build concept from the start was essential. We could inform decisions and discuss compliance with the Fire and Rescue Service, Building Control and other statutory compliance partners and stakeholders. Apart from the build itself, there were also other factors to consider such as staff training, fire response, evacuation, ongoing fire safety precautions and enriched oxygen atmospheres.

Training and response

In terms of training, while some staff would come from NHS healthcare providers, others would be from Her Majesty’s Forces, others retired and some returning staff and volunteers. As such, there wasn’t always transferable training. In-depth training was required commensurate to backgrounds.

Looking at fire response, the fire alarm configuration wasn’t as provided for in healthcare. Specifically, it wasn’t two-stage. Without continuous and intermittent and the associated cause and effect, how do staff readily investigate or know if the incident is in their compartment? This scenario was compounded by the lack of repeater panels at nurse bases and local analogue addressable fire panels.

The fire response also includes the fire response team traditionally in place at complex healthcare establishments. This may include security, shift engineers, the site matron and estates officers. As these roles were not necessarily going to be established on site, who would replicate them?

Once the investigation team was established, a procedure was required to differentiate procedures involved with going into an area deemed as ‘hot’ (ie full of COVID-positive patients). Also included in fire response was the response of the local authority Fire and Rescue Service and the understanding for them of the significant risk difference from the premises’ usual use. Then, of course, there was the need for familiarisation of the premises and healthcare procedures related to a field hospital.

Traditionally, healthcare facilities rely on progressive horizontal evacuation.  As the premises that house the Nightingale Hospital were not constructed as a healthcare facility, the lack of compartments and sub-compartments commensurate with the requirements of the Fire Code was challenging. 

Considerations around ‘defend in place’, more emphasis on training staff in the use of fire extinguishers, on site fire engines from the Fire and Rescue Service and other practical issues were evaluated during fire risk assessments. Fire action cards for both fire response teams and staff were provided in all areas and fire drills conducted with all those expected to respond to fire alarm activations.

Ongoing fire safety

Reducing the risk of a fire to as low a level as was reasonably practicable was central to the overall fire strategy. In those areas occupied by patients, a risk analysis of charging equipment, cooking, false alarms, daily checks of fire safety features and staff induction were all essential.

Enriched oxygen atmospheres were a significant concern. In our case, there was a provision of oxygen monitors at every sixth bed. Accompanying these was a procedure for staff to follow in the event of one activating. During the commissioning of the oxygen system, a simulation of all beds being used with the expected consumption of oxygen was carried out. No monitors activated. This provided a level of assurance that the fire safety calculations for oxygen omission in relation to the size of the bed-occupied areas were accurate.

The fire risk assessment – and any procedures agreed – also took into account local features that could aid fire safety measures while the building was being used as a hospital, such as any sprinklers that were fitted, local automatic fire detection, ceiling heights, built-in roof smoke ventilation and using local staff such as security officers and engineers already familiar with the building.

As the COVID crisis unfolded, it was clear that changes to the layout of hospitals and the fitted infrastructure such as oxygen systems were going to be significant requirements in swift time. Space separation, screens, social distancing and people flows through areas were all going to be key factors in defeating the disease. Understandably, the pace of change and risks posed to staff didn’t always allow full fire safety evaluation of changes that are commonplace in most healthcare facilities.

Factors that impacted fire safety were numerous. Screens provided across means of escape to separate ‘hot’ and ‘cold’ patient flows. Screens in office areas to separate staff and allow socially-distanced working. Temporary structures for the ‘donning and doffing’ of PPE. Increased mobile and free-standing alcohol hand gel stations across premises. Waste receptacles on corridors for depositing used PPE. The increased provision of oxygen cylinders across premises. An increase in piped oxygen systems. Breeches to compartmentation during the installation of medical gas systems and requests to hold open fire doors so as to reduce touch points and infection transmission. This list is by no means exhaustive, but it serves to highlight the considerations with regards to the changing infrastructure.

In addition, we had to consider that face-to-face training had to cease. Progressive horizontal evacuation was compromised. How can you evacuate one ward to another with infected patients and no infected patients? For the investigation of fire alarms, staff needed to don appropriate PPE. Then there’s oxygen enrichment in atmospheres.

The latter point is one that’s still presenting a challenge and a potentially significant risk to healthcare organisations. As the treatment of patients evolved, so did the use of oxygen and concerns were raised both nationally and internationally with regards to enriched atmospheres and the impact on fire safety. Alerts have been issued to prompt organisations to assess this risk and evaluate local procedures.

Those alerts reinforce the need to continually understand the clinical picture around oxygen distribution in hospitals and healthcare settings and its impact on fire safety. This isn’t exclusive to piped medical gases and should also take into consideration cylinders as these are used in settings for COVID-positive patients where they may not ordinarily be used.

Normal ‘day job’

While dealing with the challenges of the last 12 months, in parallel the normal ‘day job’ for fire safety professionals in the healthcare setting has necessarily continued. This was reinforced on 21 January when a fire’security incident occurred at the Leeds General Infirmary.

At 5.45 pm, the fire alarm in the Jubilee Wing activated. On investigation by staff, it was identified that there was a confirmed fire in the corridor near a temporary Emergency Department ‘donning and doffing’ area. The fire alarm was activated automatically by smoke detectors. Staff attempted to fight the fire using fire extinguishers. Despite their best efforts, the fire and associated smoke prevented safe fire suppression by an extinguisher.

Staff ensured that all doors were closed. Fire doors had closed on activation of the fire alarm. The West Yorkshire Fire and Rescue Service was automatically called. Emergency Department staff contacted the Switchboard to confirm a fire. The HUB was also contacted and the fire response team attended as expected.

The fire alarm system activated the smoke extraction system. Fire compartmentation was in place and contained the fire to the area of origin. West Yorkshire Fire and Rescue Service firefighters extinguished the fire using their own equipment. Breathing apparatus wearers were committed. Smoke would have dropped to waist height. Positive pressure ventilation fans were used by the Fire and Rescue Service to clear the area of smoke.

In the subsequent fire investigation, several factors were noted. The area where the fire started is part of a hospital street surrounded by a 60-minute, fire-resisting construction. The compartmentation is designed to allow staff and patients to remain in a place of relative safety in surrounding parts of the hospital and limit the spread and damage caused by a fire. 

The fire was extinguished well within an hour. The compartmentation worked well and prevented fire spread. The Leeds Teaching Hospitals NHS Trust has invested significant time and resources into ensuring compartmentation across the Trust’s estate is maintained, with the Jubilee Wing having undergone a programme of works over a number of years to ensure compartmentation is present and correct (with this area being part of the works). These works have potentially prevented the fire from spreading and affecting more areas along with the routine checks of fire doors and other fire safety features.

‘Wall glamour’/artwork is commonly used around the Trust’s hospitals, often covering large areas. In developing fires, this artwork (which is normally plastic-based) and its adhesive can prove to be a significant source of fuel and create quantities of toxic smoke, as well as causing fire spread. The wall art in the Emergency Department corridor (ie coloured lines on the wall) was melted by the blaze, but didn’t ignite and cause fire spread. This highlights the need to control anything in circulation routes and means of escape that could increase the risk of ignition or the effects of a fire.

Impact on the Trust

A fire at any time is a challenging scenario. Due to COVID, the Trust was already under significant pressure so the impact of this episode was compounded. Immediately and unexpectedly, there was a need to evacuate approximately 60 patients from the Emergency Department. This will have resulted in all of the patients involved receiving sub-standard care due to them being in a cold car park with a lack of full monitoring equipment available and difficulties in being able to continue to deliver treatments such as intravenous medications.

Patients from the Emergency Department were rapidly relocated on in-patient wards which will have caused an unexpected increase on those wards’ workloads. There was a very significant risk of COVID-positive and non-positive patients being mixed during evacuation. Critical care services were diverted away from the hospital. Adult and paediatric major traumas were diverted to other major trauma centres in Sheffield and Hull, meaning that the Trust was compromised in delivering a life-saving trauma service during the incident.

The Trust had to divert paediatric services away from the Emergency Department which, as the only paediatric Emergency Department in Leeds, posed a significant risk. Stroke and vascular-centric services were also diverted, again resulting in significant risk.

The cause of the fire was deliberate ignition. While it transpired, another incident – this one security-related – was playing out concurrently in the Radiology Department adjacent to the Emergency Department and involved the perpetrator of the crime. Brandishing a bladed weapon, the individual ran into the Radiology Department and threatened staff while attempting to deliberately start another fire. The suspect has since been charged with several offences.

Peter Aldridge is General Manager for Estates, Fire and Security at the Leeds Teaching Hospitals NHS Trust (www.leedsth.nhs.uk)