Evaluating the communication within fire and rescue services and the NHS on the fire risk of emollients in accordance of the MHRA safety update

The Medicines and Healthcare products Regulatory Agency update in 2018 reported 50 fatal fires linked with emollient use. It detailed the fire risk and new advice aimed at fire service and health care professionals in reporting of such fire incidents and educating the public on safer use of emollients. This study investigates how this has been communicated internally and publicly, with 52 Fire and Rescue Services (FRSs) websites and, 191 Clinical Commissioning Groups (CCGs), and 21 Local Health Boards (LHBs) formularies accessed. A Freedom of Information Request (FOIR) was also made, giving further details of implementations. Our study revealed that 63% of FRSs, 32% of CCGs and, 72% of LHBs gave no safety advice within their website or formularies. Of the 37% of FRSs and 68% of CCGs that did, only 5% and 4% were sufficiently up to date. 27% of FRSs and 28% of CCGs/LHBs revealed that they had no warning/advice internally in their FOIR responses and 25% of FRSs and, 35% of CCG/LHBs had not disseminated advice on using emollient safely to the public. We suggest improvements in safety campaigns using a multiagency and national approach and recommend organizations to educate professionals to improve reporting and effective dissemination.


| INTRODUCTION
In 2008, the National Patient Safety Agency (NPSA) issued a warning about the possible flammability of bandages and other material when impregnated with emollient products, based on 50% paraffin content or above. 1 A recent Freedom of Information Request (FOIR) from the British Broadcasting Corporation (BBC) described 37 fire deaths linked to the use of skin emollients in the United Kingdom (UK) from 2010 to 2017. 2 The Medicines and Healthcare products Regulatory Agency (MHRA) in 2018 subsequently described 50 fire deaths involving the use of emollients. 3 However, the number of fatalities is thought to be higher, owing to underreporting and the lack of awareness within the Fire and Rescue Services 4 and healthcare professionals and, among patients. 5 This is despite the MHRA report, which in part targeted such organizations and other editorials and articles trying to highlight similar concerns on the flammability of skin care products when dried into fabrics and clothing. [6][7][8][9] There have also been several media accounts 2,10,11 and coroners' reports describing the possible acceleration of fires by emollients, with the victims usually elderly smokers with reduced mobility. [12][13][14][15][16][17] The coroner's reports state that there is an increased risk of fire when emollients are soaked into clothing and bedding and recommend that more information should be available to patients and healthcare professionals.
The MHRA publication 3 requested any fire incidents linked with emollient use to be reported using their yellow card scheme. This triggered, the National Fire Chiefs Council to provide links to the MHRA advice for use by the Fire and Rescue Services and for public communication. The MHRA also provided healthcare professionals with advice on prescribing skin emollient products and how the information should be delivered to patients.
The recent message from the MHRA is not to stop or deter people from using medication, but to help people to use such products in a safer way. Currently, the MHRA are recommending that labeling and product information for emollients should include a warning about their fire risk. 3 Their previous guidance only related to products with a paraffin content of 50% or greater but has now changed to include low paraffin content and paraffin free products based on flammability tests. 18 The study showed that the mean ignition time is reduced from 60 seconds for blank cotton sheeting to under 10 seconds when contaminated with a 27.1% paraffin base cream (14.5% white soft paraffin/12.6% light liquid) and left to dry for 24 hours, using an indirect flame. The vertical flammability tests also showed quicker ignition times of polyester and cotton blend sheeting, reducing from 336 to 13 seconds with the same emollient present and dried for 24 hours. These large reduction in ignition times could have an impact on the possibility for a person to react quickly enough to remove ignited clothing or bedding especially if elderly or immobile This also raises concerns about impregnated bed sheets, surgical dressings, gowns or night wear made of blended fabrics, such as those used in hospitals or care homes. Blended fabrics exhibit inherent flame-retardant characteristics, but these results suggest that using such fabrics for bedding may not mitigate the risk, as proposed in research based on oil based contaminated flame-retardant materials. 19 It is crucial that the appropriate warnings and cautions are communicated effectively to the public and within organizations, especially in view of the wide use and variety of such products. In 2018, General Practitioners (GPs) in England prescribed over 10.5 million individual items of emollient and barrier preparations; worth over £70 million. 20 Additionally, over-the-counter purchases of these preparations' accounts for an industry worth over £2.2 billion. 21 A study has not yet been carried out on how and if these new warnings are being distributed within relevant service professions and subsequently communicated to the public. Therefore, here, we describe and measure the response to the MHRA guidance on the updated  The overall website search of FRSs and CCGs/LHBs for advice on the safe use of emollients and assessing the quality and currency was carried out between May 20 and July 04, 2019. Within the FRSs websites, the search word "emollients," "cream," and then "moisturiser" was used in the homepage search bar and then the relevant results navigated to. For the homepage of CCGs and LHBs, links to the formulary or prescribing guidelines were navigated to and any warnings were searched for. If the formulary or prescribing guideline could not be found, or obvious, a search for "formulary," "emollient," "cream," and then "moisturiser" was carried out. In the case of CCGs that used a joint formulary, this was also recorded.  The parameters used to assess the quality of warning were based upon the current MHRA published report mirrored by published information on the NFCC website 22 and the British National Formulary. 26 The quality of warning and advice on emollients was scored using the parameters in Table 1. The number of links on all the websites where the information was found was also recorded and for FRSs, whether the information was directed more to the public or to carers was also recorded.

| Analysis
All the findings (from websites and through the FOIR) and scorings were recorded in an Excel spreadsheet and summarized in Tables 2   and 3  CCGs or LHBs within the related county apart from West Yorkshire.

| Clinical Commissioning Groups and Local
Health Boards emollient safety advice in formularies  Figure 3). Similarly, public information was communicated via home safety advice rather than through FRS websites. Therefore, we were unable to assess if these different implementations were up to date for this study. Table 2 includes the scoring of the quality of warning and if available, whether it was up to date, with the largest percentages (65%, 100%, and 100%) of FRSs in Great Britain placed in the lowest score category ( Figure 1).  (Table 3).
There have been various ways that CCG and LHBs have implemented the information from the MHRA (Figure 4)  Information, but they did not change the scoring or maps. Some CCGs had updated the advice available after July 4th when our public website search concluded and therefore were not included in our scoring.

| DISCUSSION
This study found overall that warnings were poor across both FRSs and NHS services in Great Britain. Only 4% of FRSs websites contained the correct and most current information as published by the MHRA. Similarly, only 5% of health services produced a sufficient warning alongside emollient prescribing information. Extensive searching of FRSs and CCG/LHBs websites revealed differences in not only the format but also the level of information presented. In addition, navigation of CCG and LHB formularies to the correct information was often complicated and not user friendly for health care professionals and the public. Similar findings were also commented on in a study on the variations in the structure of emollient formularies on CCG websites leading to confusion for prescribers and patients. 28  Our study showed that in areas where there was a higher number of fire fatalities linked with emollients, the quality of fire safety advice shown on the FRSs website was better. However, this was not reflected on CCG and LHB websites in the same area and suggested more collaborative partnership with FRS might improve the fire safety risk awareness of the public and those working within organizations.
A number of organizations also responded to the FOIR suggesting