On February 24, 2011 a fire extinguisher hanging on the wall was accidentally bumped and then fell to the floor in an eight-bed critical care unit at IU Health Bloomington Hospital located in southern Indiana. The impact from hitting the floor bent the handle and pin causing the Multi-Purpose Dry Chemical Fire Extinguisher to spontaneously discharge its powder throughout the unit, setting off the fire alarm. At the time of the release, there were four patients on the unit. The hospital’s other two intensive care units, and eight bed critical care unit and a fourteen bed cardiovascular unit, were at full capacity.

As the fire alarm sounded at 12:42 pm arriving staff began assessing and preparing patients for evacuation. An initial assessment was performed to determine the order of evacuation based on the resource needs of each patient. Of the four patients, three were on ventilators, and the one non-ventilated patient was on Continuous Renal Replacement Therapy (CRRT). By 12:47 bed management and nursing from the unaffected critical care units began the process of creating space for these four critical patients. A Code Yellow, Level 2 for evacuation was called at 1:15. A Level 2 evacuation is used by Bloomington Hospital for situations that require a limited area, horizontal evacuation. The actual process of evacuating the patients began at 1:29 and was completed, with the result of plenty of assistance, by 1:35 pm. The only non-ventilated patient developed a slight cough and two responding staff members with a history of asthma began wheezing during the event requiring an emergency department evaluation. Visitors were only slightly impacted. One visitor was in the unit at the time of the incident and others in the waiting area had to be evacuated for safety purposes.

Multi-purpose fire extinguishers are all around work horses that have the ability to fight A, B, & C class fires by effectively smothering them, which in turn separates the oxygen and fuel. The key ingredient in these types of extinguishers is ammonium phosphate. It is a non-conductive, corrosive agent that does a good job of suppressing fire at the cost of making a complete mess. At IU Health Bloomington Hospital, nearly every square inch of the critical care unit was covered with yellow powder requiring extensive recovery efforts.

A number of key lessons were learned:

• Evacuation training and planning are keys to success. With the assistance of DQE, Bloomington Hospital was provided extensive incident management and evacuation training to hospital leadership (both onsite and online) and were provided with a comprehensive Evacuation Plan. Training needs to insure that all staff has a clear understanding of Incident Command during an incident. 
   
• Most evacuations are not emergent. Without immediate risk to life and health, the incident commander and unit leadership can take time to make good decisions that impact both the patients and affected staff. Quickly assign the Evacuation Branch roles to help streamline care. This will help prevent freelancing from staff and ensure a more organized response. 
   
• Incorporate security early in the process. Place staff/security at the entrance to the impacted location to make sure unauthorized individuals do not enter the area.
   
• Staff safety is paramount. The important roles of the Safety Officer, especially in cases like this, need to be well understood. Post signs at the entrance of the impacted area that identifies the personal protective equipment (PPE) needed prior to entry and make sure adequate supplies are readily available.
   
• Check your fire extinguishers. Make sure all of your fire extinguishers are properly secured throughout the facility.