Hospital fire fact: If a small blaze broke out next to an MRI machine, would-be firefighters couldn't use a traditional red metal extinguisher because powerful magnetism might yank it right out of their hands.

Here's another: In many hospitals, the staff most likely to cause fire code problems are from the information technology department, because of technicians' penchant for punching holes through fire walls to run new wires in hidden areas. And finally: Experts estimate that 550 to 650 patients a year nationally catch on fire during surgery, even though a primary cause—use of oxygen—can be avoided in most situations by using nonflammable medical-grade air instead.

As hospitals grow in complexity and adopt new life-saving technologies and clinical procedures, experts say healthcare providers need to bear in mind that progress also brings new legal and patient-safety risks. Fire is a major one.

Advice on how to handle fire hazards and mitigate legal risks runs the gamut, from developing detailed emergency response plans to regularly inspecting for structural problems or process-changes that could save a life. But nearly in unison, experts say the most important precaution is staff training on the fire plan.

The importance of such preparations was cast in stark relief Dec. 9, when surging flames engulfed the 180-bed AMRI Hospital in Kolkata, India, killing 93 people and resulting in charges of culpable homicide against seven hospital employees, according to the Associated Press.

A report in the Christian Science Monitor quoted newspapers in eastern India as saying that the state-of-the-art hospital lacked exit doors and an evacuation plan and had sealed windows. The local media also said the fire department took up to 90 minutes to arrive on the scene after the fire started.

The 1961 fire at Hartford (Conn.) Hospital left 16 people dead. It remains the deadliest U.S. hospital fire in five decades. Photo credit: Hartford Hospital

Meanwhile, a study released last week by the New York City Fire Department reported that between 2004 and 2006, healthcare provider facilities nationally averaged 6,400 fires a year, with those open 24 hours a day accounting for 89% of the incidents. The fires caused five civilian deaths, injuries to 175 people and about $34 million in annual property loss.

The AMRI fire came only one day after Hartford (Conn.) Hospital observed the 50th anniversary of a fire that left 16 dead in the large medical center, which hospital officials say remains the deadliest U.S. hospital fire in five decades.

“That truly was one of our darkest days,” Hartford Hospital President and CEO Jeffrey Flaks says.

On Dec. 8, 1961, someone flicked a cigarette ash down a trash chute at Hartford Hospital, eventually igniting a column of flame that blew out a protective door on the hospital's ninth floor and created what investigators later called “a wall of flame” on the patient floor, according to an account of events published last week in the hospital's staff newsletter.

“The awareness, the unintended consequences of the fire, the positive things that resulted from it, they resonate today,” says Flaks, a 2001 Modern Healthcare Up & Comer. “Truthfully, we look back at that event and study it very closely. … It's not surprising that it was possible that a fire like that could occur.”

Trash chutes and cigarette smoking in hospitals across the U.S. were restricted or outright banned soon after, and sprinkler systems were mandated—progress that Flaks credits to the thorough and transparent investigation of the fire led by the Hartford Hospital president at the time, T. Stewart Hamilton.

Today, the 157-year-old Hartford Hospital maintains an uncommonly large staff of five full-time firefighters and two part-timers to cover a campus that includes 45 patient-care buildings spread across about 70 acres.

Hartford Hospital fire marshal Michael Garrahy says the fire triggered changes in local and statewide fire policies, including a rule that dead-end corridors cannot stretch for more than 30 feet and a requirement that all areas of the building have at least two exits, including one horizontal egress and one vertical.

But legal and industry experts say hospital fire safety means much more than allowing for escape from a burning building. Often in a hospital fire, the patients can't move themselves and aren't stable enough to be moved anyway—that's why they're in the hospital.

That means that hospitals, unlike most buildings, are built to allow patients to stay inside the facility during a fire. Experts say that fact places an inordinate amount of importance on fire walls, compartmentalized spaces and flame-resistant doors and hinges—another lesson from Hartford, where a firefighter who was able to leap from an eight-story fire ladder into a ninth story window closed at least four patient doors on the burning floor.

“One of the things we learned from that was, when the doors were closed, everyone lived. When they were open, people died,” Flaks says.

Robert Solomon, division manager for building and life-safety codes at the National Fire Protection Association, says that in most cases, a complete evacuation of a building out onto the street would be called for only as a last measure in a catastrophic event.

The more common solution hospitals train for is to have staff triage patients, decide who must leave and how far they can go, and then closing every door behind them.

However, that kind of “defend in place” mentality counters what most people learned in grade school, where students typically learn to follow their teachers out the nearest door of a building. That's one reason why planners, administrators and even the national fire code itself place so much emphasis on regular training.

“Write the plan and practice, practice, practice. Keep drilling. You don't have time to pull the book off the shelf when you need it,” says Suzanne Loughlin, co-founder and executive vice president of Firestorm Solutions, a New York-based risk-management and disaster-planning consultancy in New York. “What's critical is that you have good communications with the first-responder community … They need to know what your plan is.”

Colbey Reagan, a lawyer with Waller Lansden who has advised hospitals on legal fire-safety issues, says that in his experience, inadequate fire-safety drills are a common legal compliance problem for hospitals. “It can be difficult to run a fire-safety drill in a hospital,” he adds.

In addition to local fire codes, nearly all hospitals are legally governed by the requirements of the National Fire Protection Association's NFPA 101 Life Safety Code, which is updated every three years, most recently in September, Solomon says. The Joint Commission and the Medicare conditions of participation require hospitals to comply with NFPA 101.

Reagan says fire code issues can cause legal headaches for hospitals, especially if the local fire inspectors find that an IT employer has punched a hole in a firewall to run a new cable. He says it's a good idea to have someone in plant operations make regular inspections for such holes as part of a checklist.

In terms of legal compliance, Solomon says the most recent version of the code actually loosened some restrictions, including allowing more decorative elements inside hospitals and including more flexibility for moving wheeled equipment in hospital halls, including computers, diagnostic machines and patient lifts. Rather than banning moveable equipment from corridors, the code requires hospitals to train staff on moving it out of the way in an emergency.

However, not all fires threaten the safety of an entire building. Increasingly, many fires are confined to a patient's body or face.

Patient-safety experts say the rise in surgical flash fires coincides with the growth in popularity of outpatient procedures and the related use of oxygen during sedation. The flammable gas can ignite if it comes too close to surgical instruments such as electrocautery devices and lasers, especially if an alcohol pad was also used to clean the surgical site first.

Mark Bruley, vice president of accident and forensic investigation at the patient-safety organization ECRI Institute, says three surgical fires were reported at hospitals during one week in the beginning of December.

Surgical fires remain on the institute's top 10 list of hazards in hospitals (Nov. 7, p. 18). Of the 550 to 650 surgical fires estimated at hospitals each year, about 30 are considered “serious” and one or two result in patient deaths, Bruley says. But many, if not most of them, could be prevented.

“If we can get rid of the open delivery of oxygen on the patients' face, or at least question its need, that would likely get rid of well over half of the surgical fires that occur,” Bruley says. “What's needed is a cultural change, and in order to effect that, CEOs need to buy in to the need to prevent surgical fires and mandate surgical safety changes in their ORs.”