Fires involving patients on long-term oxygen therapy (LTOT) in the home present a significant risk to patients and their relatives, neighbors and emergency service personnel. Research from 2021 based on media reports estimated that on average, someone in the United States dies every four days from a fire involving LTOT. Home oxygen fires cause over 1,000 burns each year, and medical costs can amount to nearly $10 million in some cases.
Homecare providers are aware of the danger. A 2021 survey of home oxygen installers found that a third had experienced a patient harmed by these fires; 8 in 10 reported they were fairly or very well informed about the problem.
But with at least 1.5 million patients on home oxygen and varying awareness about safety requirements, it is often unclear who is responsible for mitigating the risk of fire. Education initiatives can range from a formal statewide initiative to a polite word reminding the patient not to smoke. And where fire safety devices—thermal fuses known as “firebreaks”—are mandated, there are frequently issues with implementation due to lack of awareness around reimbursement.
Recent efforts by fire safety experts in Washington, Iowa and North Dakota have seen home oxygen installers reimbursed for thermal fuses through state Medicaid systems. This has been a unilateral approach, coordinating with a variety of stakeholders to ensure the devices reach the patient and are installed correctly.
Home Oxygen Fires & Injuries Go Underreported
A 2021 research paper established that fires involving home oxygen therapy are an underreported material public health risk. The issue is underrepresented in national data reports based on the National Fire Incident Reporting System (NFIRS), partially due to the complexity of the system. Firefighters report many “near miss” events in which there is evidence of a fire, but none was officially recorded or observed by fire personnel.
Yet analysis of media reports found that, on average, between December 2017 and August 2019, someone died every four days from a fire involving LTOT in the United States. This suggests that the death toll is likely higher than previous estimates by the National Fire Protection Association.
Smoking is the most common cause of these fires, with up to half of users continuing to smoke tobacco after being prescribed LTOT. In one review of veterans on LTOT, 89% of those who experienced flash burns said they had given up, yet 92% of those fires occurred because of smoking.
Many home oxygen patients, including those with COPD, are eligible for Medicare and Medicaid coverage. This means a significant portion of the cost of treating these injuries falls on state and federal governments. Minimizing the incidence of fires involving supplemental oxygen is therefore a concern for numerous stakeholders, including insurers, state and federal health care systems as well as homecare providers on the frontline.
Thermal Fuses—Effective Or Not?
In the United Kingdom, the mandated use of thermal fuses—alongside other safety measures like risk assessments, patient education, and the installation of smoke alarms—has virtually eliminated deaths from supplemental oxygen fires.
A freedom of information request to all clinical commissioning groups in England, where firebreaks are required, revealed that from 2013 through 2017, 63 serious incidents involving oxygen fires were recorded, including just one fatality.
Thermal fuses are installed in-line in the oxygen delivery tubing, with one placed close to the patient and a second near the oxygen source. In the event of a fire, these thermal fuse devices automatically stop the flow of oxygen.
In the United States, analysis in the 2021 report estimated that the widespread use of thermal fuses for at-risk populations could reduce home oxygen deaths from 100-150 per year to just five. Meanwhile, a 2020 study by Wake Forest Baptist Medical Center investigated the effectiveness of firebreaks in nursing homes, assisted living facilities and patients’ homes. With help from local emergency medical services and fire agencies, 225 firebreak kits (including devices and educational information) were distributed, and the number of patients admitted to the hospital as a result of LTOT-related burns dropped from 24 to nine per year.
Who Bears Responsibility for Thermal Fuses?
Despite evidence of the effectiveness of firebreaks, mandates have not always led to widespread implementation. As the 2021 survey of installers showed, just half of the installers were aware of a Veterans Health Administration mandate. Respondents were more likely to install firebreaks if requested by the patient, a respiratory therapist or the state fire marshal. They were very unlikely to do so as a contractual obligation, or just through a sense that it was the right thing to do.
The experiences of some states show how to overcome issues around reimbursement and responsibility. In Iowa, the Department of Health and Human Services opted to cover the devices, making it the first U.S. state to fund bidirectional thermal fuses through its state Medicaid system.
Meanwhile in Spokane Valley, Washington, efforts to introduce thermal fuses were led by community risk reduction specialists with funding from the Federal Emergency Management Agency. To implement the thermal fuse program, the fire department collaborated with the local hospital and supplemental oxygen suppliers. The hospital’s respiratory therapists referred at-risk patients for home fire safety visits, ensuring that these patients received safety education and thermal fuses along with their oxygen equipment.
Using additional funds from the Washington State Department of Health Trauma Program, the hospital purchased more thermal fuses and established a protocol for providing discharged patients with the safety devices. The fire department then conducted home visits to verify the correct installation and functionality of both smoke alarms and thermal fuses and is introducing an individualized home fire escape plan.
The program’s success led to increased adoption among local home oxygen providers and further advocacy efforts. A local hospital manager engaged with the Respiratory Care Society of Washington to push for statewide mandatory use of thermal fuses and collaborated with other hospitals to raise awareness. These initiatives, supported by a comprehensive communication strategy and community partnerships, have shown positive results, with no in-home LTOT-related fire or injury incidents reported since their inception in July 2022.
Momentum Is Growing for New Measures
As more states recognize the necessity of mandating and funding thermal fuse firebreaks—and as the Centers for Medicare & Medicaid Services considers a new reimbursement code—there is hope for a substantial decrease in home oxygen-related fires and injuries.
Both the American Burn Association and the International Association of Fire Chiefs have issued position statements supporting a comprehensive multi-pronged prevention approach and calling for enhanced equipment safety by medical suppliers, including the use of bidirectional thermal fuses.
For homecare practitioners, staying informed about these initiatives and advocating for broader implementation are important steps toward reducing public risk from home oxygen fires. As the outcomes from these efforts show, the implementation of thermal fuse firebreaks can significantly mitigate the fire risks associated with LTOT, ultimately saving lives and reducing health care costs.
