No Fuse, No Safety: The Hidden Risk Threatening Firefighters and Home Oxygen Patients

Key Takeaways

• In the U.S., someone dies every four days in a fire involving home oxygen therapy (HOT) systems.
• In the UK, where thermal fuses were mandated in 2006, deaths from HOT fires have been virtually eliminated.
• The U.S. Centers for Medicare & Medicaid Services declined to establish a dedicated reimbursement code in 2024, stalling nationwide implementation.

Every four days on average, a person dies because of a fire involving home oxygen in the United States. There are at least 150 fatalities annually, and over 1,000 injuries requiring emergency medical care. As a fire department, you never forget a fire involving home oxygen systems.

Two years ago, my department in Nevada, IA, responded to a call where a patient smoking on home oxygen ignited a fire which resulted in cylinder explosion. The fire and subsequent explosion lead to the home being destroyed, two lives were lost and two others injured. Medical bills for the patients topped $1.2 million. I do not think our firefighting team has ever really recovered from that terrible day. 

Preventing a home oxygen tragedy

What is so frustrating about these devastating home oxygen therapy (HOT) fires is that they are easily preventable. Just $8 buys a kit with a pair of thermal fuses (like fire breaks) that stops the flow of oxygen in the event of a fire involving the oxygen tubing. The fuses reduce its severity and spread and the widespread destruction associated with a house fire. 

They are cheap, easy to install and not only can they save a victim's life, but your firefighters' lives, too. 

Internationally, these devices are widely recognized as an effective safety measure, having been nationally mandated and adopted as standard practice in several countries. In the United Kingdom, where they were mandated in 2006, they have virtually eliminated deaths from HOT fires. In contrast, U.S. home oxygen users remain nearly 20 times more likely to die in a fire involving home oxygen systems compared to their counterparts in the UK. 

In the United States, we are in a dangerous limbo when it comes to patient safety and home oxygen fires. Over 95% of home oxygen equipment providers acknowledge the value of firebreaks, yet only a small percentage consistently install them without specific reimbursement.

We know firebreaks can save lives and limit injuries, but in too many communities, they are simply not being installed. There are still hundreds of thousands of patients on home oxygen across the country at risk, a fact that becomes apparent as we continue to hear of devastating reports of such fires across the country. On June 6, 2023, five Tacoma, WA, firefighters were injured when a ceiling collapsed on them during a large apartment building fire linked to smoking with oxygen use.  

Working towards a mandate

A decision by the U.S. Centers for Medicare & Medicaid Services (CMS) in January not to create a national reimbursement code for thermal fuse devices was disappointing. Building on a decision by the Veterans Health Administration in 2018 to mandate the device, fire safety experts, burn clinicians, homecare industry professionals, patient groups and academics have built up a compelling evidence base to advocate for a national mandate.

This is not just an ethical imperative, but an economic one, too. Last year, a national mandate was recommended after the most comprehensive cost-effectiveness analysis of thermal fuses found savings of over $300 million over 10 years. 

However, CMS argued that the current oxygen equipment reimbursement code is adequate and already allows for the inclusion of thermal fuses. From experience, we know this framework is not leading to widespread implementation. We are still seeing deaths, life-changing injuries and widespread property damage. 

Last December, we heard of a fatal fire in Plainville, MA, likely caused by smoking near home oxygen. In April 2024, Billings, MT, experienced two deadly fires involving home oxygen and smoking within a single month, prompting local fire officials to issue warnings about the dangers of open flames near medical oxygen. 

Growing awareness, state-by-state, is leading to wider implementation and a realization that specific reimbursement mechanisms are required. Iowa, Kansas, Missouri, North Dakota and Washington now cover the devices through state Medicaid. Other local initiatives, like the one at Wake Forest Medical Center in North Carolina distributed 225 firebreaks across the community. This reduced burn injury admissions from 24 to nine per year. 

The International Association of Fire Chiefs, in collaboration with burn clinicians, patient safety advocates and industry partners, also continues to raise awareness and promote the broader adoption of thermal fuses. Visit this website for an easy-to-use toolkit.

I have been working around these campaigns long enough to know we now need a coordinated, national approach. As we are seeing in Massachusetts and Montana, people believe firebreaks are still an optional add-on and are not being treated as evidence-based, life-saving fire safety devices. Any home using oxygen therapy should treat them like smoke alarms and make them an integral part of fire safety.

Conclusion

Revisiting the CMS decision would be a critical step in bringing the United States up to speed with standard HOT fire safety practices in other parts of the world. A federal reimbursement mechanism would help standardize life-saving home oxygen fire safety and ensure that patients across the country receive the same level of protection, regardless of their provider or region. A single death — let alone every four days — is already one too many. There is still much work to do.