When I started in the healthcare fire and life safety field in the late 1990s, the 1961 Hartford Hospital Fire which claimed the lives of 16 people and the classic 1978 short film “Hospitals Don’t Burn Down” (you can find it on YouTube) were still fresh in people’s minds. In both the real and fictional incidents, a fire started on a lower-level floor, raced up a trash chute, and came out an upper floor where it turned into an uncontrollable conflagration. The real incident was a bellwether for healthcare fire and life safety as it led to the codes that we live by today. The fictional incident was meant to scare the daylights out of healthcare workers to ensure they followed the fire safety rules. Until the early 1990s, smoking was allowed in hospitals and I even know some organizations who let their psych patients smoke right up into the 21^st century in “smoking rooms.” What?! Things have evolved.

Hospital buildings are now fully sprinkled and is unbelievably only a requirement of the Life Safety Code for the past 20 years. We have also changed the way hospitals are constructed. No longer can you have big, open stair towers made of wood, trash, and linen chutes that are basically unprotected chimneys or finished materials that are the equivalent to paper.  

Back then, a hospital’s fire safety program primarily depended on a two-pronged approach: fire prevention and fire response.  The fire safety department was staffed by a fire marshal or a fire chief, who was usually a retired fire fighter or fire officer from the local fire department who coordinated the program based on his experience of battling the “red devil” as a career firefighter. The rest of the department was staffed with deputy fire marshals who conducted the day-to-day work. They would check the fire extinguishers and hoses monthly. They would conduct fire drills, which included moving patients off a patient unit and sometimes down a stair tower. They would train staff how to respond to a fire. There was also the hospital fire brigade, which were usually hospital employees who responded to the fire with the express intent of fighting the fire, and saving patients and staff. This meant staff had to be trained at the level of a fire brigade annually and would respond with a fire extinguisher to the scene. This was easy if you had a one building hospital. When you have a healthcare campus and you watch an old facilities/maintenance guy lugging a 20lb dry chemical down the street on his shoulder, you have to wonder which is worse, the fire incident or the workplace injury report?

Fire Safety Today

With all these changes, what does healthcare fire safety look like today? A good friend of mine spent twenty plus years in Philadelphia in the fire service and then accepted a position as the head of safety for a large academic medical center. After a couple years on the job, he thought of fires in hospitals in the same vein as the movie “Towering Inferno” (another fine work of fiction). But after a couple of years in his new position, he realized that a fire in a hospital was more like an appliance fire:  a small amount of fire and potentially a large amount of smoke with lots of sprinkler water.  He was absolutely dead on! 

Think about incidents that you may have experienced in your facility, and how they are limited in nature. A computer, a fan, an elevator motor, or a patient smokes in the room and bed sheets catch on fire.  The worst case in the Environment of Care, you have a surgical fire that is limited to a piece of equipment in an operating room or to the patient themselves. While these are high impact events in the immediate area of the incident, they have much lower impact to the areas outside of where the incident started. We must also add that these are very low frequency events. Basically, the incident stays in the room where it starts.

As a safety healthcare professional in the 21^st century, we have a lot to balance, and need to make sure we are getting the biggest bang for our buck. With that being said, we are required to train staff to know what to do in a fire incident. This includes how to summon help, how to protect the patients, visitors, and staff, and possibly how to deal with the incident itself. This is a regulatory standard that any federal, state, or local authority is going to ask us to demonstrate when surveying or inspecting our facility. The best place to start to ensure staff know the basics is R.A.C.E. 

R.A.C.E.

Rescuing

R.A.C.E. goes beyond just knowing the five words (Rescue, Alarm, Contain, Evacuate, Extinguish). For a successful fire safety program, we need to make sure that staff understand what the acronym means and how to implement it. Rescuing does not mean rescuing everyone on the floor, but just getting the people out of the room where the incident is located.

Alarm 

Alarm means knowing where the fire alarm is located and how to activate it. Since kindergarten, we were told that only the teacher was allowed to pull the fire alarm. If we did pull it, black ink would squirt out and stain our hand so that everyone knew who pulled the alarm. Most employees have never had to pull the alarm and are scared to death to do so. The staff needs to know the fire alarm starts the process. Then a follow up phone call to the facility security department/emergency ops center lets them know that there is an actual fire in the building, ensuring everyone knows this is a real incident (Code Red-Confirmed). It also helps to get the cavalry coming, not just one security officer to investigate the routine fire alarm (that goes off all the time). 

Contain

Containing the fire means not only closing off the area where the fire is so that it does not spread, but closing all the patient doors, room doors, and corridor doors, so that the smoke and fire-rated features we have designed and built into the building, can be fully used to contain the fire and smoke. It also ensures the safety of all of the other patients. This reduces the need to evacuate more than the patients who are directly affected by the incident as the patients are kept safely in their rooms behind a smoke tight wall and a closed smoke tight door. Closing the door of the room where the incident is located will allow the heat in the room to build up more quickly thus allowing the sprinkler to activate sooner. Once the sprinkler activates this is no longer a fire issue, this is a water remediation issue. The fire is done! 

Evacuation

Evacuation should no longer be focused on emptying the unit. Our evacuation will be more limited and controlled. Evacuating the patients in the most danger and whose care could be the most compromised to an area so their care can continue is the correct procedure. I always tell staff, remember, it may be safer dealing with the fire than trying to move a patient who may be more injured or worse by the evacuation. Yes, if you can put a patient in a rolling sleep chair and have one staff member move them to the adjacent smoke compartment or across a connecting corridor to another building, do it. But if it is going to take six staff members 20-30 minutes to move an unstable ICU patient, that you may cause more harm in doing so, would it be better to secure them in their room with a nurse or caregiver and deal with the fire which, in a sprinkled building, should be extinguished in less than 5 minutes?  Evacuation should not be sudden and quick; it should be planned and deliberate.  

Extinguish

Extinguish makes me always ask: Do I want a nurse or caregiver to leave their patient and risk injury to play firefighter? Of course not!  We want staff to ensure their patients are safe and then, if they feel comfortable doing so and know how to do so, take a fire extinguisher and make one attempt to extinguish the fire. If they can’t extinguish the fire with a standard fire extinguisher on their unit, they need to back out of the room, close the door, and let the sprinkler system do its job.  If the fire is so large that it cannot be extinguished with one or two fire extinguishers, should staff really be fighting that fire?  Let that sink in. These are not trained firefighters; they are hospital staff members. And if there is no life involved, what are you saving? Think about the most expensive piece of equipment in your facility such as an MRI or a surgical robot. If that equipment catches on fire and you put that fire out, are you going to use that equipment again for patient care? NO, it is now going in the dumpster. So what are you trying to save? Something that is trash or scrap and that is equipment that costs north of $1 million dollars. Is the risk worth the reward?

I will concede that using the fire extinguisher will stop the fire. It is a worthy cause and will save on cleanup, but you need to make sure that staff understand the patient’s safety comes first and everything else in the hospital is replaceable or will dry out. What it comes down to is making sure staff are educated and know their responsibility in a fire event. 

Prevention Through Rounding Tools

The other part of modern healthcare fire safety is what we are doing to prevent fires in the facility? This could be ensuring patients who smoke are not tempted to light a cigarette in bed while they are on a nasal canula with oxygen.  Have staff educated the patient upon admission? Have they been questioned whether they have brought smoking or vaping material with them into the hospital? Have they been offered supplemental nicotine to help them overcome any urge to smoke? This is a patient-facing function in which safety professionals can work with care givers to ensure 100% compliance. 

The next step to prevention is identifying hazards in the environment of care. We have found that the best way to do this is by conducting environment of care tours or what we used to call hazard surveillance tours. This is a process of going into all areas of the building with fresh sets of eyes and finding issues that the average staff member walks by every day. This is where you find the piece of electrical equipment with the frayed cord that will catch surgical drapes on fire, the daisy chained outlet strip, or the space heater that was bought at the dollar store in the nurse’s station. If you can identify and remove these fire safety risks from our facilities, we will reduce the risk of fire.  

The key to any rounding program is not only being able to identify the issues, but how you communicate the hazard and get it remediated. While we all have used a paper and pen and sent an email, it is 2025. So shouldn’t we be embracing technology and using a tool that allows us to identify the hazard, assign it to a responsible party, and ensure it has been remediated? Tools like Soleran Healthcare’s Environment of Care Tours (EC Tours) can improve the efficiency and effectiveness of your touring/rounding program and reduce the time staff take to alert leaders and find resolutions. Soleran Healthcare also has a tool called Fire Safety Manager for all your fire drill scheduling, fire watches, fire incidents, and more. Embrace technology. 

Fortunately for us, fires in hospitals are not as prevalent as they were prior to the 1990s. In some ways that makes it more challenging for the fire safety professional since it is not something on the mind of staff. The safety professional must now be more nimble and creative knowing that the chances of them dealing with a fire in their facility are much lower than they used to be, and the overall risk to the facility is much lower than it used to be. But the potential for that small incident to affect the hospital’s operations still exists. We no longer need a fire brigade walking around with fire extinguishers, but we have to put the effort and energy into ensuring that our program stays focused. When that incident does happen, it is handled in an efficient manner so that patient care never even notices it happened.

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