According to the 2009 edition of the Emergency Care Research Institute Health Devices Guide, operating room fires rank third on the top 10 technology hazards. ECRI estimates that between 550 to 650 fires occur in operating rooms in the United States. The most common sites where fires were the head, face, neck and upper chest (Hart, MD et al. 2011) which means that patients are disproportionately at risk compared to patients exposed to fire risks in other parts of a hospital.

Fire hazards in Operating Rooms

I’ve had the opportunity to participate in the design or implementation of fire protection and life safety systems at different stages in several hospitals across Latin America. In these projects, fire professionals have recognized the importance of protecting the operating room from fire and electrical risks. The risk is heightened considering the cost of the medical equipment that exists there, but not many people really grasp the level of risk that exists during surgery.

The risk is heightened considering the cost of the medical equipment

Fires in these type of places are especially deadly because they might occur directly on the skin or air ways of patients on oxygen enriched environments. Hospital designers and planners should focus on prevention first, and with the help of medical experts create an environment where the likelihood of a fire is kept to the minimum, and where doctors and nurses have access and means to put down fires and keep patients out of harm.

Common fire sources

The most common fire sources that can be found in this type of environment are medical PPEs, such as gowns, hood and masks, drapes, towels and sponges that cover or are used over the patient’s skin, as well as plastic tubes and accessories directly attached to the patient and that might go into the airways. There are also different kinds of flammable chemicals and alcohol-based solutions used to prepare and clean the patient and the presence of medical gases. ECRI considers the patient’s skin and hair can be considered as fire sources as well, when certain conditions are met, like high oxygen concentrations on the air.

According to the ECRI guide, 68% of fires in operating rooms were caused by electrosurgery equipment and other electrical hemostatic devices. In these environments prone to high concentrations of oxygen, any spark can become a potential ignition source. Between the medical equipment that might cause sparks, you can find: high speed surgical drills, defibrillators, lasers and electrocautery units. Of course, the most obvious ignition sources found in an OR are damaged cables and wires.

The NFPA 99 (Standard for Fire Protection in Healthcare Facilities) considers that medical air and gas distribution systems have an inherent risk of fire and explosion associated with them, because these gases can act as oxidizers and create ideal conditions for ignition. Many studies indicate that almost any material can ignite with oxygen concentrations on the air above 30% (normal O2 concentration on the air is 21%). It’s also important to mention that nitrous oxide used in anesthesia supports combustion the same manner as oxygen (Hart MD. Et al. 2011).

Types of Fires and how to minimize their risk 

According to the ECRI, fires in the operating room environment can be divided into fires that occur in the OR environment, like ignitions on medical equipment or materials stored or located around the operating table, and fires that ignite directly over the skin and airways of the patient. Many studies consider that 44% of fires over the patient’s skin are in the face, neck, head or upper chest and 21% on the airways.

“The basic elements of a fire are always present during surgery” says Mark Bruley, vice president of Accident and Forensic Investigation on ECRI. “Slow reaction or the use of improper firefighting techniques and tools can lead to damage, destruction or death”. This calls for active involvement of the medical staff, including surgeons and anesthesiologists, in fire prevention training and pre-surgery planning.

The basic elements of fire, such as oxygen, are always present during surgery

Fire prevention in pre-surgery planning

ECRI and the FDA (Food and Drug Administration) strongly recommend that surgeons and nurses should include fire prevention and possible hazard identification during their pre-surgery planning. “Each one control a specific side of the fire tetrahedron and by properly managing their technique and part of the equation, surgical fires can be avoided” says Bruley.

Medical staff should identify the location of gas and oxygen shutoff valves and evaluate the need of oxygen concentrations above 25%. Organizations like the OMS recommend avoiding the use of open oxygen sources on the face during procedures and use tracheal tubes or laryngeal masks instead. Also, it’s a good practice to use floor to ceiling drapes to create a barrier between the oxygen-enriched atmosphere around the operating table and the rest of the room.

Staff should participate in drills and training on the use of firefighting equipment

Also, ECRI recommends that all the staff should participate in drills and training on the use of firefighting equipment and rescue and escape methods. In case of a fire, all oxygen and medical gas sources need to be managed, and medical equipment removed or relocated (if possible) if they are directly affected by fire or the fire extinguished in place.

It’s important to note that ECRI and other institutions, like the World Health Organization, recommend that fire extinguishers should be used only after the patient has been safely removed from the hazard. In extreme cases of fires over the patient’s skin, ECRI says that a CO2 extinguisher is preferable because they minimize tissue contamination and damage.

Fire Protection Equipment in the Operating Room

The IFC (International Fire Code) and the NFPA 99 and 101 (Life Safety Code) provide several guidelines to manage fire safety in healthcare facilities.

Fire protection means can be passive or active, and one of them doesn’t exclude the other. Passive fire protection serves the purpose to minimize fire spread through ventilation, electrical wiring and openings through walls and windows. They need to be designed to keep flames and smoke from nearby fires away from the operating room, and to prevent smoke and flames that might occur inside one operating room to spread to the nearby areas.

These protections include, but are not limited to:

  • Walls, floors and ceilings should not only be fire rated for 120 minutes, and doors for at least ¾ of that time, but to be constructed in a manner that they are sealed to prevent smoke and flame leakage inside and outside.
  • Use of fire stoppings in all ventilation, electrical and other kind of ducts that go through fire rated walls, floors or ceilings.
  • Use of intumescent coverings in all structural and non-structural elements.
  • Use of fire-retardant furniture, although is important that almost no material is fire retardant in atmospheres where the oxygen concentration is over 30%.
  • Dampers and smoke control systems.

All electrical systems and medical air, gas and oxygen distribution systems should be designed according the guidelines of the NFPA 70 (National Electrical Code) and the NFPA 99.

Active fire protection

Active fire protection includes automatic detection and alarm and extinguishing measures

Active fire protection includes automatic detection and alarm and extinguishing measures. Fire extinguishers should be located for easy access and clearly identified by a plastic sign from the wall to the ceiling.

Even though the NFPA 101 recognizes that fire sprinklers are mandatory in healthcare facilities, they should not be activated during an active surgery because this water might contaminate open wounds. In fact, ECRI recommends against the use of any water-based fire extinguished in operating rooms, including water mist systems. Also, the ECRI mentions that water that pools near or below medical equipment can cause electric shocks to the occupants.

Regarding automatic detection and alarm, point type smoke detectors are not recommended for this type of application because they can accumulate dust, and regular dust contains levels of dead human tissue that might contaminate the environment.

early fire detection 

Operating rooms call for early detection to avoid damages to costly medical equipment, but most importantly to minimize the risk and exposure to smoke and flames to staff and patients. The preferred detection method for this kind of application is aspirating smoke detection. Considering that operating rooms usually use forced ventilation, international guidelines propose the use of high sensibility detectors. The EN 54-20 prescribes Class 1 o Class 2 sensibility for rooms with high velocity air changes.

Bosch Security and Safety Systems offer the Invisible Type smoke detector which doesn’t use a smoke chamber to detect smoke particles, but instead uses a state of the art technology and patented infrared source arrangement that allows it to be completely flat and with no openings. This detector can be easily cleaned, and with the IP66 back box accessory it doesn’t accumulate any dust whatsoever. Duct smoke detection should be installed in the air conditioning ducts to activate dampers and smoke control systems.

As with fire extinguishers, manual pull stations should be properly located and identified to allow medical staff to give alert of a potential fire hazard.

Notification appliances

Notification appliances activate in specific areas of the hospital

In the event of a fire, notification appliances activate in specific areas of the hospital, related to the fire location and risk. Inside operating rooms only visible notification is recommended, because audible signals might affect patient’s wellbeing. Voice evacuation should be activated in common and prepping areas nearby the operating rooms. All the fire detection and notification devices shall be connected to a central Fire Alarm panel (FACP) to allow staff in charge of fire and evacuation response to receive timely information and make real time decisions.

The panel and all the systems related to fire detection and evacuation should be installed according to the NFPA 72 (National Fire Alarm and Signaling Code), EN 54-14, BS 5839 or any local relevant guidelines.

Proper maintenance of all passive and active fire protection systems and regular training and preparation from medical staff and doctors are critical to minimize the risk of fires in operating rooms. Prevention is the first step, but when fires occur, optimal outcomes depend on coordinated team efforts (Hart MD. Et al, 2011). Also, a comprehensive fire safety program should be implemented in all hospital areas, including operating rooms.

Share with LinkedIn Share with Twitter Share with Facebook Share with Facebook
Download PDF version Download PDF version

Author profile

Ivan Paredes Tamayo Head of Product Marketing for Latin America – Fire Detection and Life Safety, Bosch Security Systems

Ivan studied Electronic Engineering and Automation and has almost 19 years' experience in the fire prevention and fire detection fields as a chief designer and project manager for several integration companies.

He served as Firefighter and Urban Search and Rescue specialist for the Guayaquil Fire Department for 8 years.

Working as Head of Product Marketing in Bosch Security and Safety Systems, he is responsible for the development of the fire detection business within Bosch, with a focus in strengthening relations with the fire prevention community and authorities in Latin America, promoting fire prevention knowledge for engineers and society, and creating safer buildings.

In case you missed it

No Easy Solutions: Complex Causes Surround Growth Of Wildfires
No Easy Solutions: Complex Causes Surround Growth Of Wildfires

Understanding the underlying causes of wildfires enables us to control them better over the long haul. One element is climate change, which has created conditions prone to wildfires by increasing heat, changing rain and snow patterns, and shifting plant communities. But there are also other contributing factors in the growing scale and intensity of wildfires. One is the condition of the forests in Australia, California, and other areas where the incidence of wildfires has increased. In California, for example, it is well known that the forests are unhealthy and in need of more prescribed burns and other thinning efforts. However, given California’s 33 million acres of forest land, more than half of it publicly owned, even an ambitious effort like addressing the needs of a million acres a year would require decades to fix the problem. managing the landscape We as a society need to decide how we can restore our forests, and start a conversation about what that looks like" “We know that getting our forests back to a healthy state will be the most effective way to cope with fires in the future,” says Jessica Block, Associate Director for Operational Programs at the WIFIRE Lab at the University of California San Diego. “However, massive fires are destroying the ability of forests to recover." The goal is not to stop wildfires but to understand the role of fire as part of the natural processes of managing the landscape. “We as a society need to decide how we can restore our forests, and start a conversation about what that looks like,” adds Block. “We should think of forests as a system we live in, and a system that we should be able to live in. Understanding the system is the goal, so that we can make all the right decisions in the future.” identify and control wildfires Fires are eating up forests that are way too dense and that have way too many standing trees, and state and federal agencies alone cannot solve the problem. Furthermore, the stakes are literally life and death: Thousands will die, whether in the wildfires or from the effects of inhaling smoke. The negative impact on long-term health is impossible to measure. Especially troubling is the impact of wildfires at the so-called wildland-urban interface (WUI), where growing population centers border on wildlands at risk of fire. Current fire models are not designed for these areas, so more work is needed to address these specific risks. Almost everyone agrees that the solution is to identify and control wildfires at early stages before they get out of control and turn into huge fires that impact millions of acres. automatic detection capabilities Today, postings on social media are an early warning sign but may not identify the exact location of a fire New technologies are helping to identify nascent wildfires. One option is the addition of automatic detection capabilities to the AlertWildfire network of cameras that currently keeps watch throughout five Western states to provide early warning of wildfires. So far, human volunteers have been used to track the cameras, but automation is on the horizon. One application of machine learning is to detect a smoke flume. A critical element is the ability to tell the difference between smoke and clouds, which humans can easily differentiate but is difficult to automate. With machine learning, computers should be able to “learn” the difference. Soon, mechanisms will exist to detect the location of a fire via multiple inputs - web cameras, social media and satellite images. Today, postings on social media are an early warning sign but may not identify the exact location of a fire. Working together, the other tools can help to pinpoint the location. Alerts to fire dispatchers must be verified as real to avoid misuse of resources.

Australia’s Moonshot: To Be Global Leader In Wildfire Prevention, Resilience
Australia’s Moonshot: To Be Global Leader In Wildfire Prevention, Resilience

Andrew and Nicola Forrest have committed 50 million Australian dollars (US$35 million) to the Fire and Flood Resilience initiative through Minderoo Foundation, with a goal of raising an additional 450 million (US$320 million) in direct or in-kind support over the life of the program. The goal of the ambitious investment is to make Australia the global leader in fire and flood resistance by the year 2025. It is an audacious vision that requires an innovative approach, and the organization takes inspiration from the U.S. Apollo mission of the 1960s. In effect, it will be a “moonshot” to advance the cause of preventing and controlling wildfires. Specifically, the first mission, Fire Shield, seeks to ensure no dangerous bushfire in Australia will burn longer than an hour by 2025. respond to wildfires The Flood and Resilience Blueprint further seeks to provide every community in Australia the skills and resources to cope with fire and flood disasters. Finally, it seeks to provide “healthy landscapes” by improving ecosystems to be “immune” to fire and flood disasters. Founded in 2001, Minderoo Foundation exists to arrest unfairness and create opportunities to better the world  “We are not daunted by or afraid of taking on the toughest challenges,” says Karen O’Connor, Missions Lead for Minderoo Foundation’s Fire & Flood Resilience initiative. "Fire has a devastating and unfair impact on communities all around the world - and if we can help drive better approaches to prevent and respond to wildfires, we can have a profound influence.” Founded in 2001, Minderoo Foundation exists to arrest unfairness and create opportunities to better the world. black summer bushfires Minderoo Foundation stepped up after Australia’s black summer bushfires in 2019-2020 to help communities respond to and recover from the devastation. The organization also seeks to do whatever it can to mitigate the risk of large-scale damage due to bushfires and build resilience to future disasters. “We understand that fire and flood are critical ecological processes that enable many of Australia’s ecosystems to function, supporting regeneration and new growth,” says O’Connor. “Therefore, Fire Shield does not aim to prevent wildfires entirely but rather to prevent wildfires from becoming disasters.” ground truth data Fire Shield will progress using the “Mission” methodology that involves breaking down major problems into smaller elements that can be addressed in turn. Missions are outcome-focused and time bound. They rely on accurate baseline and ground truth data and an ability to measure impact to know when the mission has succeeded in its goal. Fundamental to the Mission approach is bringing the best people and expertise to the challenges at hand Fundamental to the Mission approach is bringing the best people and expertise to the challenges at hand - whether they are working in scientific research, in government, corporations or philanthropy. Having accurate data and measures are also essential. To that end, Fire Shield is working with partners to develop an ecosystem for data standardization and sharing in order to collectively leverage insights to address future hazards. emergency services “It is also about making sure that people working in fire and emergency services are provided with the right information, in a timely manner, to make the best decisions when responding to fire,” says O’Connor. An example is Fire Shield’s partnership with the Australasian Fire and Emergency Service Authorities Council to support all Australian emergency services to develop new capabilities for fire detection, information sharing, fire simulation and response as well as utilizing data for improved decision-making wherever they are. fundamental principles “No matter what we do, Minderoo Foundation is always guided by the evidence,” says O’Connor. Minderoo Foundation’s Fire & Flood Resilience Blueprint has brought the best available evidence and expertise together to lay out a resilience blueprint for Australia and to inform the design and selection of missions, including Fire Shield. It challenges us to go right back to scientific principles and look for the best possible solutions” Importantly, the Blueprint is a “living document” that can evolve as the evidence base grows. First order problem solving is about going to the fundamental principles that apply to a problem, rather than thinking through analogies or accepted wisdom. “It challenges us to go right back to scientific principles and look for the best possible solutions,” says O’Connor.  important resilience problems The initiative is committed to working collaboratively. To date they have secured more than 50 partners across corporations, governments and civil society - and they are always open to more. They are also actively looking to collaborate with international programs with similar goals, to ensure they can multiply rather than duplicate efforts.  “We intend to share and publish our work widely, and of course continue to build collaboration, which is central to our approach,” says O’Connor. “We see ourselves as an enabler encouraging, facilitating and convening dialogue among different organizations and sectors of society to identify the most important resilience problems - and get to solutions faster.”

The Origin Of One California Wildfire Was A Gender Reveal Party
The Origin Of One California Wildfire Was A Gender Reveal Party

An explosion of blue-colored smoke on Sept. 5, 2020 in Yucalpa, California, was the beginning of a large wildfire in El Dorado Ranch Park. The pyrotechnic device was essentially a smoke bomb designed to send plumes of pink or blue smoke rising into the air, designating the gender of an expected baby. The expectant dad had packed the target with a highly explosive substance called Tannerite and shot it with a high-powered rifle. The target was designed to explode in pink or blue to reveal whether the couple was expecting a boy or a girl. Flammable foliage When the device ignited, so did the dry, wild grasses growing up to 4 feet tall in the meadow at the park, 80 miles east of Los Angeles. In the peak of summer, Southern California foliage is extremely flammable, and there were already fires burning across the state. After being active for 11 days, the fire had affected 18,506 acres and was 63% contained. The family that sparked the fire sought to put down the flames using water bottles. Then they called 911. The responsible individuals were still at the park when firemen arrived, and there are also surveillance cameras. Wildfire Spread And Evacuation The fire spread from the park to the north on to Yucalpa Ridge that separates Mountain Home Village and Forest Falls from the City of Yucalpa. The fire threatened a nearby residential neighborhood, and some 21,000 people were evacuated. After being active for 11 days, the fire had affected 18,506 acres and was 63% contained. The pyrotechnic show was a variation on the popular trend of gender reveal parties, which seek to announce the gender of an expected infant in increasingly (and competitively) colorful and/or dramatic ways. The parties are often featured prominently on social media. Rising temperatures Also contributing to the fire was recent weather in California, whose terrain was scorching in record-breaking temperatures as high as 120 degrees F in early September. The California Department of Forestry and Fire Protection (CAL Fire) reminds the public that, with the dry conditions and critical fire weather, it does not take much to start a wildfire, and those responsible for starting fires due to negligence or illegal activity can be held financially and criminally responsible. Natural conditions and human activity Natural conditions are central to causing wildfires, although human activity can provide the triggers Natural conditions are central to causing wildfires, although human activity can provide the triggers, including downed power lines, sparks from tire blowouts, and barbecues that get out of control. The pivotal gender-reveal part is just the latest example. If not for the increasingly dry and scorched conditions that make wildfire so easy to ignite, such human events would be much less consequential. With thousands of acres of wildfire raging across California, the cause of one wildfire seems less important in the overall scheme of things. However, the event does emphasize how seemingly minor events can have a very large impact. Lightning and fireworks Another cause of recent wildfires was lightning with more than 10,000 lightning strikes sparking 376 fires on Aug 16 and 17, 2020. In a season of wildfires, use of fireworks, for whatever reason, is a particular risk. Fireworks cause an average of 18,500 fires each year in the United States. Of those, about 1,200 injuries are from less powerful devices such as small firecrackers and sparklers.