Q: We are getting ready to complete our fire drill schedule and need clarification. When conducting fire drills how many remote fire zone/smoke areas are required to be observed and findings recorded? We could not find anything specific in the standards that address this.
A: You won’t find the answer in the current edition of the Life Safety Code or the accreditation standards because it isn’t there. It used to be in the standards back years ago, but the requirements to have observers in other zones during fire drills were dropped. What is now required for fire drill observation is generally identified as staff who work in buildings where patients are housed or treated must participate in drills according to the hospital’s fire response plan. That does not mean a fire drill has to be conducted on every unit. It means staff must participate in fire drills according to your fire response plan. Most hospitals use the acronym R.A.C.E. to describe their fire response plan, which requires staff to confine the fire by closing doors. So, if the fire is on the 4th floor west wing, staff on the 1st floor east wing can only close doors based on the fire response plan. How do you confirm that staff participated in a fire drill on a particular unit? By sending someone to walk through and observe if they closed the doors. Since the standard does not say all staff must participate in all drills, then I see no reason to have observers in every unit during every fire drill. I see a more realistic approach of having a program of observing every unit at least once per year. Depending on the physical size of your hospital, you might be able to observe every unit once per year with just a couple of observers per drill. So, the bottom line is you still need to confirm that staff participated in the drills, which usually equates to having observers… it’s just that the accreditation standards do not specify how many units need to be observed during a drill.