Fire Alarm Activated During Fire Drills

Q: We recently had a consultant advise us to always activate our fire alarm system whenever we conduct a fire drill. We don’t always do that because we perform so many fire drills we think the staff will ignore the alarm when there really is a fire. What do you see as the standard for fire drills?

A: I believe your consultant is correct, with the exception when a drill is performed between the hours of 9:00 pm and 6:00 am. Here is why: Section 19.7.1.2 of the LSC specifically requires the activation of the fire alarm system during drills, along with the transmission of the fire alarm signal. I asked the NFPA to clarify what is meant by the phrase “transmission of the fire alarm signal” and a representative said the intent means to transmit it to the point where you involve everyone in your fire plan. I also asked a representative from CMS how they view the phrase “transmission of the fire alarm signal” and they interpret it to mean the signal needs to go all the way to the fire department for each fire drill. Since the fire department is a large part of your fire response plan, they need to be included. The same section in the LSC also says you do not have to activate the fire alarm system during the hours between 9:00 pm and 6:00 am, as to not disturb sleeping patients. A fire drill is an excellent opportunity to document that the fire alarm transmission signal was received by the local fire department, even if you contract through a vendor to monitor your fire alarm panel. You are required to do so anyway, every quarter. Make sure you document it on your fire drill report.

Fire Drills Performed on Every Unit

Q: Is every nursing unit in our hospital required to have one fire drill per shift per quarter? Our Director of Quality says we are required to do so, but that seems too many to me.

A: No, I do not see any LSC requirement or Joint Commission requirement for a fire drill on every nursing unit per shift per quarter. What I do see in the LSC is a requirement for drills to be conducted quarterly on every shift, to familiarize the personnel with the signals and emergency action required under varied conditions (see section 18/19.7.1.2). The purpose of the drill is to test and evaluate the efficiency and knowledge of the staff in implementing your organization’s fire response plan. This can be accomplished by having observers recording the reactions of the staff in compartments away from where the alarm was initiated. The Joint Commission standards on fire drills (EC.02.03.03) are similar in wording and intent. Drills conducted between the hours of 9:00 pm and 6:00 am do not have to activate the fire alarm notification system, as the intent is not to interfere with patient sleep patterns. Other requirements you may be interested in knowing; every time you conduct a fire drill, the fire alarm signal is required to be transmitted so the fire department actually receives notification. Also, no more than 50% of the drills are permitted to be announced. And having the switchboard operator announce overhead “Code Red: This is a drill” every time the fire alarm is activated for a drill constitutes an announced drill, in my opinion. In summary, most hospitals that I visit conduct 12 fire drills per year; one drill on each shift per each quarter. Each drill evaluates the staff’s response in many different locations throughout the hospital utilizing trained observers.