Dear editor,

Healthcare institutions are vulnerable to disruption from events such as earthquakes, fires, and floods, and the damage incurred can endanger the lives of patients in the hospital.[1] In this type of scenario hospital staff have primary responsibility for the hospitalized patients’safety, since patients are neither fit to respond to such a disaster, nor do they know how to respond.[2,3] The situation becomes more difficult and challenging if the disaster occurs in critical care areas such as intensive care units (ICUs) and operating rooms, due to the complexities involved in moving acutely ill patients who are reliant on organ support and invasive monitoring.Here we report on one such incident involving a fire that occurred in a 10-bed ICU in our 2000-bed public sector tertiary care teaching hospital in Northern India.The hospital has a robust fire prevention and fire fighting system that includes a fire control room and fire Officers who are responsible for ensuring strict compliance with statutory and regulatory aspects of fire safety round-theclock, seven-days-a-week. Various reports from around the globe describe fire incidents in ICU settings that include evacuations,[3] promoting fire safety,[4] managing fires,[5,6] and preparedness and crisis management strategies.[7] This case report adds to this body of research, and describes a fire incident and summarize the lessons learned in the ICU of a hospital.

一般企业库存成本主要由订货成本、存储成本（库存持有成本）和缺货成本三类构成，即库存成本=订货成本+存储成本+缺货成本。

CASE

The Intensive Care Unit at Level-II, of the hospital,is equipped to provide critical care for patients. On Friday, September 11, 2015, at about 8:15 pm, the alarm panel in the fire control room flashed, indicated that a fire incident had occurred in the ICU. The security guard posted at the entrance of the ICU telephoned the fire control room, and within three minutes the fire and security guards had rushed to the site—where thick black smoke had reduced visibility to almost zero—with the necessary fire fighting equipment. A three-pronged action was initiated immediately that involved evacuating the patients, containing the fire, and extinguishing the fire.

Nine patients had been admitted to the ICU prior to the fire incident. Five ambulatory patients were moved first, after which three others were moved in wheelchairs to a ward two fl oors above the ICU, and the last patient,who was on a ventilator, was evacuated to an adjacent ICU. The anaesthetist subsequently coordinated the ventilated patient’s transfer to the Main Intensive Care Unit on the same floor. All these patients were actively assessed for any evidence of inhalational injury, and none of the patients required additional/enhanced treatment as a result of the event.

Fire fighting personnel initially started dousing the fire using fire extinguishers. A short time later a fire hose was operationalized and used to apply water to the blaze.Once the fire had been extinguished the unit’s fixed glass windows were smashed open, and high-intensity blowers were used to pump out the smoke. Doors to the Respiratory ICU across the corridor were kept closed,to prevent smoke circulating into that area. It became apparent, however, that smoke had moved into the Nephrology Unit one floor down through the common heating and air conditioning (HVAC) ducts. With the help of engineers this unit was shut down, and exit doors were opened to clear the air. By 8:25 pm, fire and security personnel had completely extinguished the fire,after which the process of clearing the smoke out of the unit continued for almost two hours.

During the fire, the following are needed: a timely response; well organized evacuation of patients; espirite de corps among all the healthcare workers; a roundthe-clock functional command centre; and effective communication.

Funding: None.

Prior planning includes: a well-trained fire fighting team with a fire officer; the availability of essential fire fighting equipment; a well-documented and rehearsed disaster and evacuation plan; ongoing staff training;and strict implementation of statutory and regulatory compliance by the management.

DISCUSSION

Hospital fires, and especially those in ICUs, affect a vulnerable population, since most of the patients might be unable to escape because they are dependent on invasive monitoring and organ support. Such incidents have occurred in hospital ICUs in the recent past, and these events have drawn the attention of policy makers to prevent such catastrophes in future. Our report and the initial investigation con firmed that various materials kept in the ICU storeroom were the source of the fire.This finding is consistent with other reports that found in 33% of hospital fires studied, general materials had beenthe first to ignite.[8] Though the consequences were less serious in our incident, the following tools might help prevent a possible catastrophe in future.

Table 1. Timeline of events

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A formal investigation was conducted by the Security Chief and Fire Officer to identify the cause of the fire. It was learned that material such as linens and chemicals,had been stored at the site of the fire. The fire may have been caused by a chemical reaction between stored carbolic acid crystals and some other material such as linen, but the exact cause of the fire required further investigations.

At 10:30 pm the area was declared smoke-free,and the in-charge nurse again assumed responsibility for the ICU, which was strewn with equipment, burned materials, and shattered glass. Administrative staff and clinicians agreed that all nine patients would be transferred back to the unit before morning ward rounds.After the debris had been removed, the area was cleaned,washed, and fogged for disinfection. Meanwhile, hospital engineers repaired and reinstalled the doors, window panes, and other structures that had been damaged during the fire. By 7:00 am the ICU was operational,and all nine patients were returned to the ICU before the commencement of routine consultation rounds at 8:00 am (Table 1).

This report provides compelling evidence, as also described by Yarmohammadian et al,[9] that sound management based on scientific principles should be used to prevent fires in the future, and to develop a viable disaster response strategy in the event a fire does occur. Therefore, these precautionary measures may be implemented to prevent other fire incidents in ICU’s and operating theatres (OTs).

CONCLUSION

From the incident, we learned: installation of exhaust system in ICUs to avoid smoke accumulation; chemicals/combustible materials should be stored separately,properly, and in minimum quantities; installation of ventilation cut-outs systems to prevent the spread of fire and smoke to neighbouring units; periodic maintenance of fire fighting and life-safety systems.

Ethical approval: Not needed.

在“一带一路”建设得以如火如荼开展的大背景下，沿线各国均需要大量人才。以经贸方面为例，“一带一路”沿线国家就需要大量懂外语、懂法律，具有丰富跨国文化知识的经贸专业人才。在“一带一路”战略的影响下，我国高校招收“一带一路”沿线国家来华留学生的规模在逐年扩大，但整体招生规模仍然偏小。以辽宁省为例，辽宁省高校招收“一带一路”沿线国家来华留学生人数由2014年的15 193人增加至2016年的17 130人[7]，也仅用了三年时间。但分摊至各高校，每所高校招收的“一带一路”沿线国家来华留学生人数就相对较少了。招生规模整体偏小影响了“一带一路”建设人才的培养，对“一带一路”建设与发展较为不利。

A limitation of this case report is that the sequence of events that occurred was not documented purposefully,and, as a result, it may contain omissions or sequential differences for some events. Future studies may focus on formal collection of information that will help policy makers draft adequate hospital response plans.

conflicts of interest: No any benefits have been received from a commercial party related directly or indirectly to the study.

虽然固定效应能去除不随时间变化的个体效应，能够很大程度上消除内生性问题，但如果内生性来自其他暂时未发现的因素，回归结果的一致性就需要慎重考虑。本文假设被解释变量存在二阶自相关，建立如下的动态面板模型：

递阶层次结构分为三个层次，分别为目标层、准则层和方案层。目标层只包含一个要素，一般是分析问题的预定目标或期望实现的结果；准则层包括了实现目标所涉及的中间环节，由若干层次组成，包括所需考虑的准则、子准则等；方案层表示为实现目标可供选择的方案、措施［5］。

③ 低 MLR组（MLR≤0.2）患者 87例（33.9%），高 MLR组 （MLR＞0.2）患者 170例（66.1%）。两组患者的TNM分期的差异有统计学意义（P＜0.05），高MLR组患者TNM分期晚。

Contributors: ND proposed the study and wrote the first draft. All authors read and approved the final version of the paper.

REFERENCES

1 Safe hospitals in emergencies and disasters: Structural, nonstructural and functional indicators.World Health Organization Web site. http://www.wpro.who.int/emergencies_disasters/documents/SafeHospitalsinEmergenciesandDisastersweboptimiz ed.pdf. Accessed November 14, 2016.

2 Aggarwal A, Bhogal R, Gupta A, Kumar A. Innovative use of digital fire to improve fire-fighting skills in a tertiary care hospital. International Journal of Medicine and Public Health.2015;5(4):336.

3 Cybulski P. Evacuation of a critical care unit. Dynamics.2003;14(3):21-3.

4 Kelly F, Hardy R. Promoting fire safety on intensive care and in theatre. Safe Anaessthesia Liaison Group Web site. https://www.rcoa.ac.uk/system/files/SALG-FIRE-SAFETY_0.pdf. Accessed November 16, 2016.

5 Kelly FE, Hardy R, Cook TM, Nolan JP, Craft T, Osborn M, et al. Managing the aftermath of a fire on intensive care caused by an oxygen cylinder. Journal of the Intensive Care Society.2014;15(4):283-7.

6 Kelly FE, Hardy R, Hall EA, McDonald J, Turner M, Rivers J, et al. Fire on an intensive care unit caused by an oxygen cylinder.Anaesthesia. 2012;68(1):102-4.

7 Sankaran K, Roles A, Kasian G. Fire in an intensive care unit:Causes and strategies for prevention. CMAJ. 1991;145(4):313-5.

8 Medical facility fires. Topical Fire Report Series Web site.https://www.usfa.fema.gov/downloads/pdf/statistics/v9i4.pdf.Accessed November 14, 2016.

9 Yarmohammadian MH, Alavi A, Ahmadi F, Fatemi M,Moghadasi M. An investigation of the status of preparedness and crisis management restrictions in hospitals of Isfahan University of Medical Sciences. Int J Health Syst Disaster Manage.2016;4((1):58-62.