FIRE SAFETY PLAN
“Code Red – Location”
DEFINITION:Smoke and/or flame has been detected visually or by fire suppression equipment.
MITIGATION / PREPARATION
· Structural Integrity of Facility
· Equipment / Supplies
· Employee Awareness
· Staff Education
· Established Relationship with External Agencies
· Preventative Maintenance Program / · Hospital Incident Command System (HICS) Implementation
· Response Plans
· Drills / Staff Education
· Mutual Aid and Sheltering Agreement (MASA)
· Equipment and Supplies
· Communication Systems
· Hazardous Vulnerability Analysis
· Life Safety Risk Assessments
RESPONSE / RECOVERY
· HICS Activation
· Staff Activation
· External Agency Activation
· Emergency Event Announcement
· Communication Systems / · Damage Assessment
· Evaluate Structural Integrity
· After Action Report / Review
· Inspect and Service Equipment
· Replenish Equipment and Supplies
· Plan Structural Repairs
· Submit Reimbursement
· Maintain HICS
· Re-entry Plan
TITLE: Fire Safety-Emergency Response Procedures
PURPOSE:
To assure the safety of patients, visitors, and staff, emergency procedures and a standard response to fire or the potential of fire, defined plans are required. This fire plan provides for both the emergency response procedures and the standard responses for all staff within the Spartanburg Regional Medical Center to an activation of the Fire Alarm, or to conditions that indicate the presence of a fire in the area.
ORIGINATION DATE: 5/2003 / KEYWORDS: Fire, Response, RACEREVISION DATES: 11/2004, 4/2005, 10/2007 / REVIEW DATES:
10/26/2007
RESPONSIBILITY: All SRHS Staff.
POLICY: In the event of a fire, the staff will follow the basic plan for the area they are in. Staff will use the acronym "R.A.C.E." when responding to a fire in the hospital and will always relocate horizontally first in a fire situation, then vertically if required. Staff will evacuate using the stairwells and/or outside, as appropriate.
Staff will use the same plans for fire drills as they do in actual events. Fire drills will be observed, to measure the effectiveness of staff response, as well as the response of building fire systems.
The HICS Incident Commander in conjunction with the local fire authority will direct hospital evacuation. The need for relocation or for evacuation will be based on the situation, and the direction of senior management. Once the Fire Department is present, command authority will be relinquished to them.
I. DEFINITIONS
A. Fire
A fire is any situation where flame, or visible smoke is seen, and/or where a strong smell of smoke is noted. Where any staff member has a strong sense of, or feeling that a fire is occurring, that will be enough to implement this plan. Operation of the Fire Alarm System, either automatically, or by manual initiation is also considered a fire, even where no cause is later found. All fire alarms will be treated as fires, until the cause is found, or no cause can be identified.
B. Hospital or Hospital Building
The Main Campus is a healthcare occupancy, based on the 2000 edition Life Safety Code definitions (NFPA 101, Chapter 19). This building houses and facilitates treatment of four or more in-patients who are unable to seek self-preservation because of treatment, mental or physical condition.
C. Regional Outpatient Clinic
Certain areas in the Regional Outpatient Clinic are designated as business occupancies, based on the 2000 edition Life Safety Code definitions (NFPA 101, Chapter 39). These are areas where patients are treated, but three or fewer patients are unable to seek self-preservation by reason of treatment at any one time and patients are not housed overnight.
D. R.A.C.E.
“R.A.C.E.” is the standard acronym for the steps of the HOSPITAL fire response plan. The initials “R.A.C.E.” stand for:
R - Rescue persons from the room or area where the fire is located, and audibly spread the alarm calling "Dr. RED".
A - Activate the fire alarm system by pulling the fire alarm pull station in the area, AND by phoning the operator and stating the situation and location.
C - Close all doors, to rooms, in corridors, and at stairs. This prevents spread of smoke.
E - Extinguish the fire, if practical, and without undue risk to life.
E. Relocation (Horizontal Evacuation)
The actions taken to move patients, if needed, from the immediate scene of the fire, through smoke or fire barriers, to an area of safety, generally on the same floor, although often in a different building. Staff in the area may implement relocation, if conditions warrant.
F. Evacuation (Vertical Evacuation)
Removal of all persons from a building; this is rarely done in hospitals - however, there must be a plan for its implementation. Evacuation would normally be done on the direction of HICS Incident Commander or the Fire Department. Evacuation should be considered as an extension of relocation, to move all patients outside of the building, or to alternate buildings.
IV. PROCEDURES
The Fire Plan should be implemented:
A. Upon activation of the fire alarm system, unless it is an announced test
B. During a fire or suspected fire
C. During a Fire Drill
D. During training relating to fire preparedness, if so directed.
Roles and Responsibilities of Staff and Others at Fire Scene
1. General Response to a fire situation, or drill in the Main Building is:
R - Rescue people from the fire room or area. Remove the people from any room where a fire, smoke, or strong smoke smell exists. Close the door after everyone is out. Don’t remove patients from the room of the fire on their beds, (except ICU gurney/beds) as they may jam in the doorway, and permit smoke to escape or enter. If patients are ambulatory - assist them out of the room. If they are nonambulatory, use a wheel chair, ordinary chair, or blanket drag; or if trained staff is available, a lift and carry technique.
A - Sound the alarm. The verbal alarm is "Dr. RED". Avoid the use of the word fire, as it may cause unnecessary panic. Pull the nearest fire alarm pull station. This activates the alarm; and indicates the location of the fire automatically.
AND
Call the Operator. This is a redundant system, to assure occupants are alerted. The operators will phone the Fire Department with what additional information they have, and assure the alarm was received. They will also page "Dr. RED" and the location, as additional direction to responding staff.
C - Close Doors! This is a critical step, to minimize the spread of smoke. In most multiple patient death fires, the deaths have resulted from smoke going into patient rooms. Closing all doors is a critical step to prevent additional deaths or illness. All room (i. e., corridor) doors should be closed, as quickly as practical, even if no smoke is seen. Patients should be returned to their rooms, or into other rooms, with closed doors. This is a primary task of all staff in all areas of the hospital during a fire emergency.
E - Extinguish the fire, if it is reasonably safe to do so. In many cases the fire can be extinguished quickly by a fire extinguisher with little risk. Due to hospital staffing, most hospital fires are found while in the incipient stage. If the fire has grown to proportions that make it unsafe, or staff feels it is unsafe attempting to extinguish the fire, they should close the door, and wait for the Fire Department to respond.
2. Relocation
If the fire situation is such that smoke invades other patient rooms, or the Fire Department/HICS Incident Commander or designee directs that patients be removed from rooms adjacent to the fire area, patients will be relocated to areas beyond the fire and smoke barriers. The patients should be moved inside rooms in the relocation destination, unless this is impossible, to protect them from smoke.
3. Elevators
Elevators should not be used in the building where the fire is located unless so directed by the Fire Department. It is acceptable when necessary to use elevators in the adjacent, fire separated buildings (through the fire separations) to move patients to other floors, where they may receive care more effectively.
4. Staff Location
Remain where you are during a fire alarm or fire drill. To protect patients and staff, the fire and smoke doors will close automatically. Staff should not open those doors except to relocate patients (on command). Stay where you are - do not move from zone to zone.
Only a limited number of staff is designated to respond to the scene of the fire, ALL OTHERS SHOULD REMAIN WHERE THEY ARE. This is important, to reduce the spread of smoke and flame, and to maintain the compartmentalization of the buildings. DO NOT RETURN TO YOUR NORMAL DUTY STATION if you are away from that area. No area should be without sufficient staff at any time to react to a fire emergency, so staff should not return until after the "All Clear".
5. Medical Gases
DO NOT TURN OFF OXYGEN, except when told to do so by the HICS Incident Commander or Fire Department, and after all oxygen dependent patients have been provided with portable oxygen, or relocated to areas where they can be served. The Charge Nurse on each unit is responsible for turning off oxygen after it has been determined that no oxygen dependent patients are connected to piped oxygen in that zone.
6. Observers
During each drill, a designated trained fire drill observer will complete the Dr. Red Evaluation Form for each area being drilled. This form will be returned to the SRMC Safety Officer within a day of the drill for review and follow-up on recorded deficiencies.
Regional Outpatient Clinic (Business Occupancies)
Staff Response at Area of Fire
This plan is for the medical practices and clinics located in the Regional Outpatient Clinic that are designated as Business Occupancies.
On hearing the Fire Alarms, or on other notification of a fire, staff should:
1. Begin to move patients and staff to designated fire exit stairwells. If patients are unclothed, or need preparation to move, they should be asked to dress, or prepare.
2. Staff should begin to check all rooms and areas, to assure no patients, visitors, or staff remains behind. Areas should be cleared from the more remote areas towards the fire stairs. Check in closets, and other areas where someone might hide.
3. Patients who cannot move by stair should be:
A. (Most Ideal Scenario) moved through fire doors to an adjacent building
B. Moved to stairwells with adequate space on landings, to hold the patients until fire department responds
C. (Used only as a last resort) be carried at least one floor down from the area of the fire.
NOTE: Non-ambulatory patient movement is never attempted during fire drills, and would only be done in a real emergency where the fire was on the floor on which the patient was held, and no alternate method of patient movement was practical. Stair Stretchers or stiff-backed chairs should be used for such transportation.
4. Each private medical practice should designate staff in their respective business to check all areas, and close doors, as practical. Suitable methods should be defined on each floor to designate areas that have been checked to assure no patients, visitors, or staff is inside. The designated person should be the last person off of the floor.
5. Staff and patients will be moved down the stairwells, to the outside, or to the interior of the Main Building, as deemed appropriate, depending on the condition of patients, and weather conditions.
6. Staff will gather patients and visitors at designated locations (primary or secondary) so that a head count may be done, to assure that all patients, visitors, and staff are accounted for, to the degree practical. A head count, and practical roll call will be done during each evacuation and alarm.
7. During Fire Drills, a designated trained observer will complete the Dr. Red Evaluation Form for each area being drilled. This form will be returned to the Safety Officer within a day of the drill for review and follow-up on recorded deficiencies.
Staff Response Away From the Fire Zone
Hospital (Main Building)
Staff in other areas of the hospital should take action upon announcement or activation of the fire alarm, and should:
1. Close doors: This is a critical step in all areas, to minimize the spread of smoke. Even if there is no smoke visible or no smoke odor, doors should be closed until the drill or activation is over. This includes all room doors, smoke and fire doors, doors to hazardous areas, and doors to stairwells. As practical, minimize staff using fire and/or smoke separation doors until the activation is cleared.
2. Check Equipment: Check fire extinguishers, pull stations, and other fire response equipment. This assures it is available and clear and helps reinforce the locations of this equipment.
3. Discuss relocation of patients: This might include checking what equipment is available to move patients. If the area with the fire is on the same floor, you should prepare to receive patients being relocated (e. g., identify empty areas in rooms, check what equipment you can use to assist them in moving patients, etc).
4. Assure all staff members know their role, and what they should be doing during the emergency (By questions and discussion). Be sure the staff members know their role, both in case of a fire in that unit, and in the case of a fire in another unit.
5. Assure that physicians and other LIP in the area know their respective roles.
Fire Drills in the Hospital (Main Building)
In order to assure the safety of staff and patients, and that all staff know their roles, frequent fire drills are done throughout the hospital. In each fire drill, staff is expected to react the same as they would in a fire situation:
1. At the scene of drill initiation, the staff should react as they would in a fire, reporting the fire, closing doors, and assuring fire extinguishers are available. They should also know where to relocate patients, and where to get equipment as needed.