Fire & Life Safety

Fire & Life Safety

Fire and Life Safety is a duty shared by many departments and is a fairly complex program. The program has been developed to encompass testing of the fire alarm systems, testing of the emergency equipment, developing employee and departmental response and maintaining a safe working environment. There are many requirements set on the institution regarding a Fire & Life Safety program, many regulations come from the Boston Fire Department (NFPA regulations) and the Joint Commission.

The Environmental Health & Safety Department conducts routine fire drills in all BIDMC operated buildings and checks for regulatory compliance during hazard surveillance and laboratory audits to ensure compliance set by these agencies.

For any questions regarding regulatory questions, or on any Fire & Life Safety program, please contact the Environmental Health & Safety Department at 617-667-3088. For any problems with fire safety equipment, please contact the ServiceResponseCenter at extension 2-0070.

For more information on the following programs, please scroll below:

• Fire Response Program (Code Red Policy)
• Departmental Emergency Evacuation Program (Floor Marshall Program)
• Building Alarm Summary & Description
• Fire Extinguishers
• No Smoking Policy
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Fire Response Program (Code Red)

Alarm Activation Procedures

In the event of a fire, the alarm system must be activated, and may be done so as a result of detected fire or smoke event (smoke/heat sensors) and the manual activation of the fire alarm pull box. Any activation of the alarm system will immediately initiate the Code Red response described in this document. In the event of fire, and you are located at any of the following locations, East and West Campuses, and local off sites (Research North and 109 Brookline Avenue), employees should manually activate the fire alarm system (pull box) and utilize the 2-1212 emergency code phone line for Code Red responder notification initiation.

When contacting the emergency number, 2-1212, employees must be prepared to give the following information: Type of Code emergency (Code Red); Location of emergency (building, floor, room number); caller’s name and callback number.

Follow the R.A.C.E. response plan:
• R: RESCUE (anyone in immediate danger, close patient doors)
• A: ALARM (pull the fire alarm, call 2-1212 emergency line, report CODE RED)
• C: CONTAIN (isolate area of fire, close door)
• E: EXTINGUISH (only if trained and fire is small/manageable) or EVACUATE the area immediately

At other “off-site” areas, such as Lexington, Chelsea and other clinics, occupants should manually activate the fire alarm system (pull box) and contact 9-911 for fire assistance and follow building specific procedures based on the Fire Response Program policy.

Roles and Responsibilities in Code Red Events

During a Code Red event it is the responsibility of all employees to ensure a safe environment for patients and other employees. Employees are expected to respond to a fire or smoke emergency by implementing the appropriate BIDMC Code Red response plan: R.A.C.E. Employees shall follow unit specific floor evacuation plan guidelines and take direction from their assigned floor marshal. In the event of a fire, you should await instruction from your designated Floor Marshall. Each department has developed an emergency evacuation plan and part of that plan was to designate a Floor Marshall.

The Floor Marshall is responsible for carrying out specific floor evacuation plans as well as; take charge of the unit response upon incident, verify Code Red report has been made to emergency call line, assure designated individuals, check all rooms and hallways for patients and visitors, prepare for evacuation if deemed necessary, follow all other aspects of floor evacuation plan and give direction to primary responder entering the smoke compartment.

First responders to the scene (Public Safety, Maintenance Operations, EH&S) will take direction from the Floor Marshall as to the location of the fire and floor emergency evacuation procedures. A Public Safety Officer will escort the Boston Fire Department to the scene, and all employees must await instruction from either the Administrator on Call or the Fire Chief to evacuate the area.

Training on Departmental Procedures

Department managers are responsible for assuring all staff are appropriately trained in hospital and department specific fire safety and response, initially upon hire, after a job change and annually thereafter. Department managers are responsible for the implementation and education of staff relating to their role and the implementation of the BIDMC Floor Marshal and department evacuation program. The Environmental Health & Safety Department conducts fire drills on a routine basis to ensure that all emergency equipment is present and functioning properly and that all involved employees are aware and trained in emergency procedures and their responsibilities in these events.

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Departmental Emergency Management Plan

The Departmental Emergency Management Plan is a tool designed to serve as a quick reference for employees in the event of an emergency in their specific work areas. Each department in the hospital has its own unique procedures, services, and specific emergency response plan, therefore it is important to familiarize yourself with the designated plan of the floor you will be on. Each department must have their own procedures developed, for the Departmental Emergency Management Plan template, click here, please contact your floor administrator or department manager for more information on your department specific plans in the event of an emergency. For questions on how to implement your plan or for any other questions, please contact the Environmental Health & Safety Office at 617-667-3008.

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Building “CODE RED” Alarm Summary

The following is a list of alarm summaries that describes how each building’s fire alarm system works. It is important to listen to your buildings alarm system to ensure proper response in the event of a code red emergency. For any questions regarding how your specific buildings fire alarm system works please contact EH&S department at 7-3088.

WEST CLINICAL CENTER
• When the alarm is activated, all occupants will hear a series of three short tones six times. At this time the strobes will flash on all floors in the WestClinicalCenter.
• A recorded overhead page will be the next step in the CODE RED process. This message will play two times and the recorded message will be: “Attention please. The signal you have just heard indicates a report of an event in this building. You should await further instructions while this report is being verified. If further action is necessary, you will be instructed to follow floor response plans.” This announcement will be heard on every floor.
• If you hear a “whooping” sound (which is your evacuation signal), you must evacuate the unit as outlined in your departmental emergency evacuation plan. This “whooping” sound will be heard on the floor of and above of the actual event.
• If you do not hear the whooping sound on your floor after the recorded message, then you DO NOT need to evacuate.

FARRBUILDING
• When the alarm is activated, all occupants will hear a series of five short tones one time. At this time the strobes will flash on all floors in the Farr building.
• A recorded overhead page will be the next step in the CODE RED process. This message will play two times and the recorded message will be: “Attention please. The signal you have just heard indicates a report of an event in this building. You should await further instructions while this report is being verified. If further action is necessary, you will be instructed to follow floor response plans.” This announcement will be heard on every floor.
• If you hear a “whooping” sound (which is your evacuation signal), you must evacuate the unit as outlined in your departmental emergency evacuation plan. This “whooping” sound will be heard on the floor of and above of the actual event.
• If you do not hear the whooping sound on your floor after the recorded message, then you DO NOT need to evacuate.

PALMER BAKER SPAN
• When the alarm is activated, all occupants will hear a series of five short tones one time. At this time the strobes will flash on all floors in the Palmer Baker Span.
• A recorded overhead page will be the next step in the CODE RED process. This message will play two times and the recorded message will be: “Attention please. The signal you have just heard indicates a report of an event in this building. You should await further instructions while this report is being verified. If further action is necessary, you will be instructed to follow floor response plans.” This announcement will be heard on every floor.
• If you hear a “whooping” sound (which is your evacuation signal), you must evacuate the unit as outlined in your departmental emergency evacuation plan. This “whooping” sound will be heard on the floor of and above of the actual event.
• If you do not hear the whooping sound on your floor after the recorded message, then you DO NOT need to evacuate.

LOWERY MEDICAL OFFFICE BUILDING
• When the alarm is activated, strobes will flash on every floor.
• A recorded overhead page will be the next step in the CODE RED process. This recorded message will be: “Attention please. The signal tone you have just heard indicated a report of an emergency in this building. If your floor evacuation signal sounds after this message, walk to the nearest stairwell and leave the floor. While this report is being verified, occupants on other floors should await further instruction.” This announcement will be heard on every floor.
• If you hear a “whooping” sound (which is your evacuation signal), you must evacuate the unit as outlined in your departmental emergency evacuation plan. This “whooping” sound will be heard on the floor of and above of the actual event.
• If you do not hear the whooping sound on your floor after the recorded message, then you DO NOT need to evacuate.

SHAPIRO CLINICAL CENTER
• When the alarm is activated, all occupants will hear a series of four short tones three times. At this time the strobes will flash on all floors in the ShapiroClinicalCenter.
• A recorded overhead page will be the next step in the CODE RED process. This recorded message will be: “Attention please. The signal tone you have just heard indicated a report of an emergency in this building. If your floor evacuation signal sounds after this message, walk to the nearest stairwell and leave the floor. While this report is being verified, occupants on other floors should await further instruction.” This announcement will be heard on every floor.
• If you hear a “whooping” sound (which is your evacuation signal), you must evacuate the unit as outlined in your departmental emergency evacuation plan. This “whooping” sound will be heard on the floor of and above of the actual event.
• If you do not hear the whooping sound on your floor after the recorded message, then you DO NOT need to evacuate.

RESEARCH NORTH
• When the alarm is activated, all occupants will hear the audible alarm system. The audible alarm will be heard on all floors. At this time the strobes will flash on all floors in the Research North building. There will be NO overhead page heard.
• In the event that the audible alarm is heard or strobes are seen flashing, everyone must promptly evacuate the building as outlined in your departmental emergency evacuation plan.
• Occupants are not to re-enter the building until authorized by Environmental Health and Safety, Public Safety, or the Boston Fire Department.

EAST CAMPUS
• East Campus has a bell code system to identify a CODE RED location. This bell code system is tied into fifteen buildings here on the east campus.
• Upon activation, all strobes throughout the East Campus will flash.
• Following the strobes will be a series of bells that will sound throughout the entire complex in a specific numerical fashion. This series of bells will be heard three times. Once activated, the bells will sound for approximately thirty seconds. By counting each series of bells one will be able to detect the bell code. This bell code can then be matched with one of the numerous bell code charts located on the East Campus, most commonly found near a pull station. Each bell code has a specific location adjacent to it on the chart. It is here on this chart that you will find what floor the CODE RED is taking place.
• It is important to remember that the ShapiroClinicalCenter differs from the East Campus alarm system considerably. Please refer to the specific Shapiro information located above.

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Fire Extinguishers

Portable fire extinguishers are classified to indicate their ability to handle specific classes and sizes of fires. Labels on extinguishers indicate the class and relative size of fire they can be expected to handle. The BIDMC maintenance department provides and ensures that all fire extinguishers are checked on a monthly basis to meet regulatory standards. The following describes the types of fire extinguishers available, and the appropriate extinguisher for each class of fire.

To report a missing or un-mounted fire extinguisher, please contact the ServiceResponseCenter at extension 2-0070. For questions regarding the training and use of fire extinguishers, please contact the Environmental Health & Safety Office at 617-667-3088.

Class A Fires: Involve ordinary combustibles such as wood, paper, cloth, rubber, and some plastics.
To prevent class A fires:
• Properly dispose of combustible waste after supplies are stocked or used.
• Utilize storage bins, hoppers, and trashcans.
• Segregate combustible materials from ignition sources.
• Place oily rags in covered containers.

Either class A or ABC fire extinguishers may be used to extinguish these fires. These extinguishers cool the material that is burning below its ignition temperature and soak the items involved so they cannot re-ignite. DO NOT use carbon dioxide or BC rated extinguishers to fight class A fires.

Class B Fires: Involve flammable or combustible liquids such as gasoline, kerosene, paint, paint thinners and propane.
To prevent class B fires:
• Do not refuel gasoline-powered equipment in a confined space, especially in the presence of an open flame.
• Do not refuel gasoline-powered equipment while it is hot.
• Keep flammable liquids stored in tightly closed and spill proof containers.
• Store flammable liquids away from spark-producing sources.
• Use flammable liquids only in well-ventilated areas.

Use foam, carbon dioxide, BC rated, or multi-purpose dry chemical extinguishers to fight a class B fire. The above extinguisher removes the oxygen from the fire, preventing the vapors from reaching the ignition source or inhibiting the chemical chain reaction.

Class C Fires: Involve energized electrical equipment such as appliances, switches, panel boxes, and power tools.
To prevent class C fire:
• Look for old wiring, worn insulation, and broken electrical fittings. Report any of these to your supervisor.
• Prevent motors from overheating by keeping them clean and in good working order.
• Investigate any appliance or electrical equipment that smells strange. Unusual odors can be the first sign of fire.
• Do not overload wall outlets. Two outlets should have no more than two plugs!

Use carbon dioxide, BC rated, or multi-purpose dry chemical extinguishers to fight a class C fire. The above extinguisher will extinguish energized electrical fires by using an agent that is not capable of conducting electrical currents. DO NOT USE WATER EXTINGUISHERS ON ENERGIZED ELECTRICAL EQUIPMENT.

Class D Fires: Involve flammable metals such as magnesium and titanium.
To prevent class D fires:
• Be sure to keep these materials in a sealed container until point of use.
• Keep flammable metals away from ignition sources.
• Be sure to know proper handling procedures of these flammable metals.

Extinguish combustible metals such as magnesium, titanium, potassium, and sodium with dry powder extinguishing agents specially designated for the material involved.
Use a dry powder extinguisher that is specially designated for the material involved. In most cases, the above extinguishers will absorb the heat from the material, cooling it below its ignition temperature.

HOW TO OPERATE A FIRE EXTINGUISHER

When using a fire extinguisher, always remember the acronym P.A.S.S.

• P – PULL the pin, this will break the tamper seal and allow you to discharge the contents of the extinguisher.

• A – AIM low and point the extinguishing nozzle at the base of the fire.

• S – SQUEEZE the handle to release the extinguishing agent. When the handle is compressed, it opens an inner canister of high-pressure gas that forces the extinguishing agent out.