Oct 02 2017

Fire Drills in Operating Rooms

Category: Fire Drills,Operating Room,Questions and AnswersBKeyes @ 12:00 am
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Q: What are the requirement for operating room fire drills per Joint Commission, CMS, and AORN? Are operating room fire drills required to evacuate patients?

A: I cannot speak to what AORN suggests for fire drills, but keep in mind their standards are voluntary since they are a professional organization and not an authority having jurisdiction. On the other hand, CMS and Joint Commission’s standards are regulatory compliance and they are not optional; you must comply with them.

Joint Commission says the following under standard EC.02.03.03 for fire drills:

  • Drills are conducted once per shift per quarter in buildings defined as healthcare occupancy
  • Drills are conducted quarterly in buildings defined as ambulatory health care occupancy
  • Evacuation of the patients during the drill is not required
  • In buildings leased or rented by the hospital, drills are only required in the areas that the hospital occupies
  • In freestanding buildings classified as business occupancies, drills are conducted once per every 12 months
  • At least 50% of the drills are unannounced when quarterly fire drills are required
  • The conditions for fire drills are varied, and the drills are held at unexpected times
  • During fire drills, staff participate in the drill in accordance with the hospital’s fire response plan
  • Drills that are conducted between the hours of 9:00 pm and 6:00 am may use an alternative method to notify staff instead of activating the audible alarms of the fire alarm system
  • After the drill, the drill must be critiqued to evaluate the fire safety equipment, the fire safety building features, and the staff’s response to the drill. This evaluation must be documented.

CMS refers to the Life Safety Code, and in addition to the above, section 19.7.1 of the 2012 Life Safety Code says the following:

  • Fire drills in healthcare occupancies must include the transmission of a fire alarm signal
  • Fire drills in healthcare occupancies must simulate emergency fire conditions
  • Bedridden patients are not required to be moved during drills

All of the above would apply to any and all drills conducted at the healthcare facility, including those conducted in the operating rooms.

So, to answer your specific question, for fire drills in an operating room, the above regulations would require you to do the following:

  • Conduct fire drills in operating rooms and ensure that staff participate in the drill in accordance with your fire response plan. This may mean they are engaged in a drill that originates in their particular room, or perhaps the drill originates in another room, but they must respond to the drill. Their response may very well be different.
  • The drill must include the activation of the fire alarm system. This is a requirement. If the drill is conducted between 9:00 pm and 6:00 am, the audible notification devices (horns, bells, chimes) may be silenced.
  • The drill must include simulated conditions. This can be a pretend fire in a waste container or an electrical pretend fire. Some organizations use a revolving red light to simulate a fire condition.
  • At least 50% of the drills are unannounced. This means you cannot page “Code Red – This is a drill” during the drill, since that announces it is a drill.
  • Simulated patients must be moved to another smoke compartment during the drill. If relocating the simulated patient in the OR is not feasible due to the simulated surgery in progress, then alternative action must be taken to protect the patient.
  • Observers are needed to critique the response of the staff, the response of the fire alarm system, and the response of the building’s fire-safety features. The LSC and the Joint Commission standards do not say where you observe and how many observers you have, but logic dictates that you need to observe where the simulated fire is at, and in other compartments. How many other compartments? There is no direction on how many other compartments so you get to decide.
  • The fire drill critique must be documented, and the expectation is the summary of the drill is reported to the Safety Committee.

However, Since CMS adopted the 2012 edition of NFPA 99, they are now enforcing the new requirement for fire drills in OR surgery found in section 15.13.3.10.3 of NFPA 99-2012, which requires annual fire drills in operating rooms and surgical suite locations.


Aug 16 2017

Fire Drills for Off-Site Locations

Category: Fire Drills,Questions and AnswersBKeyes @ 12:00 am
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Q: I have a question that is still a little fuzzy regarding fire drills. My hospital is partners with a separate clinic. Several of the clinics throughout the community have hospital employees working there (PT, Imaging etc.) but the building is owned by the clinic. Who is responsible for running drills and testing the emergency operations plan? On a side note, some of the clinics are Rural Healthcare Clinics, so the hospital owns the clinic and it operates under the hospitals CMS number but all of the employees are clinic employees not hospital.

A: Yes… I could see where this would be a fuzzy issue for you. Here is how I suggest you address this issue:

  • Your hospital has an interest in the clinics
  • Your hospital has staff that work in the clinics
  • Your hospital has patients that receive care in these clinics

Therefore; you are responsible for all testing, inspecting, and maintenance of all the fire-safety equipment, and you’re responsible for all drills (EM and fire), as well as meeting the requirements for management plans, EOPs, and policies and procedures.

An AHJ will very likely determine that since you have staff and patients in these facilities, they must fall under the hospital’s rules/standards for Emergency Management, Physical Environment, and Life Safety. That means you need to have copies of the documentation that all of the fire-safety devices were tested and maintained, and copies of all drills were conducted.

Now… if you have a great relationship with your partner clinic, and they perform all of the testing and inspecting requirements, and the drill requirements, then that is fine. You can use copies of their reports as evidence of compliance. But you still need to include these clinics in your management plans and EOP scope of work.

The bottom line is… as long as you have staff and /or patients in these clinics, then your accreditor will very likely expect that you comply with all of the hospital standards at these off-site locations.


Aug 14 2017

Unannounced Fire Drills

Category: Fire Drills,Questions and AnswersBKeyes @ 12:00 am
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Q: Somewhere I read that at least 50% of fire drills had to be unannounced. I don’t find that requirement in NFPA Life Safety Code so it may have been a Joint Commission requirement. We use DNV now and announce very few of our drills but I would like to know if there is any such requirement.

A: You are correct in saying that Joint Commission has a standard on this issue, but the Life Safety Code also addresses this as well. Look at section 4.7.4 of the 2012 Life Safety Code. It says drills shall be held at expected and unexpected times to simulate the unusual conditions that can occur in an actual emergency. While this section does not state 50% of the drills have to be unannounced, the assumption is that unexpected equates to unannounced.

Actually, DNV standard PE.2, SR.6 says healthcare occupancies shall conduct unannounced fire drills. So, it appears DNV wants all their fire drills to be unannounced, not just 50% of them. So, it looks like you should be doing all of your fire drills as being unannounced.


Mar 29 2017

Quarterly Fire Drills

Category: Fire Drills,Joint Commission,Questions and AnswersBKeyes @ 12:00 am
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Q: There is a matrix floating around on the web that describes Joint Commission’s compliance for fire drills. It breaks the quarters down as Q1=January, February, March, and Q2=April, May, June, etc. Does this mean that for a first shift drill last run in April, we can have the next drill run in September and still be compliant, + or – 10 days?

A: No, not for Joint Commission. In their Overview to the Environment of Care chapter in the Hospital Accreditation Standards manual, Joint Commission says quarterly or once per quarter means “every three months, plus or minus 10 days”. Now, I’ve heard Joint Commission engineers say they will allow this to be interpreted as follows: If the drill was conducted on April 15, that means three months from April is July. July plus 10 days means August 10 and July minus 10 days means June 20. So, according to the engineers from The Joint Commission, the window of opportunity is 51 days: from June 20 to August 10. That scenario would apply to any date the drill was conducted in April.

But to be honest, the Overview of the Joint Commission manual doesn’t say that. Other people are interpreting the Overview to mean if the drill was conducted on April 15, then 3 months after that is July 15. July 15 plus 10 days is July 25, and July 15 minus 10 days is July 5. That leaves you with a 20-day window of opportunity. 20 days is significantly less than 51 days, so you will be at the mercy of the surveyor to determine which one they enforce.

But in the past year, CMS has stated unofficially that they do not like any scenario that allows more than 3 months for a fire drill. In other words, they don’t mind the “every three months, minus 10 days”, but they don’t like the “every three months, plus 10 days”.


Mar 23 2017

Quarterly Fire Drills

Category: Fire Drills,Questions and AnswersBKeyes @ 12:00 am
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Q: We are required to conduct a fire drill every quarter. If I did one on March 22, when is the earliest and the latest dates that I can do the next one?

A: It depends on who your AHJ is. CMS would allow it to be conducted anytime during the quarter so the next drill could be done as soon April 1 or as late as June 30.

HFAP requires 3 months from the previous activity, with the next drill performed during the third month. So 3 months from March 22, is June 22, the 3rd month would be June, so the next fire drill should be conducted anytime in June.

Joint Commission requires 3 months from the previous activity plus or minus 10 days. But they have a different interpretation on how this is calculated: Three months from March 22, is June. Plus 10 days is July 10, and minus 10 days is May 22, so according to their interpretation, the next quarterly fire drill can be between May 22 to July 10.

But be aware: CMS does not like the idea that a quarterly fire drill could be conducted beyond the quarterly time period. Since the March 22 fire drill was conducted during the first quarter, they would want the second fire drill conducted during the second quarter, and July is not in the second quarter.


Jan 16 2017

Too Many Extra Fire Drills

Category: Fire Drills,Questions and AnswersBKeyes @ 12:00 am
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Q: We have a building adjacent to our main hospital (separated by a two hour fire wall) that is a mixed occupancy.  There are three stairwells that serve this building, but one has been taken out of service for emergency egress due to a large construction project outside. I have been conducting two fire drills per shift per quarter in this particular building for almost two years now and I fear I have fire drilled our employees in that building to the point that they have become desensitized to the fire alarms.  It’s my understanding that the fire drill frequency can be specified in our ILSM policy.  Here’s my thought – I’d like to state in our ILSM policy that any project lasting longer than a year will no longer require additional fire drills.  That is; a whole year’s worth of additional drills is plenty and more drills can actually have a negative impact instead of a helpful one for our fire response efforts.

A: I think your thought process is valid and sound. Conducting too many fire drills does in fact desensitize one to an actual event. Since the accreditation organizations do not specify exactly what your ILSM policy must say, then I agree that you can reduce the number of ‘additional’ drills based on the length of time that the deficiency exists.

However, the accreditation organization will be somewhat suspicious of this action so you need to be prepared. Do a risk assessment identifying the pros and cons of doing additional fire drills for an extended period of time. Have the risk assessment draw a conclusion. Present this risk assessment to the Safety Committee and ask them to review and approve it. Make sure you get the committee’s response into the minutes. If challenged by a surveyor about doing less than the traditional amount of fire drills for ILSMs, then present the risk assessment and a copy of the Safety Committee’s minutes as evidenced of a thoughtful and considerate decision. The surveyor may accept your position and he/she may not. It’s a crap shoot.

On another point… is the stairwell that has been removed from service a ‘required’ means of egress? If there is a chance you can get your architect to deem the affected stairwell is not a required means of egress, then you can declare the stairwell is no longer a required means of egress and ILSM would not be needed. That means since the stairwell is not a required means of egress then blocking off the discharge is not a Life Safety Code deficiency. If you go that route, make sure you get a decision in writing by the architect and run that through your Safety Committee.


Oct 02 2015

Do Table Top Exercises Count as Fire Drills?

Category: Fire Drills,Questions and AnswersBKeyes @ 12:00 am
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 Q: Do table top exercises count as a fire drill? We are updating our old policies and traditionally it has been allowed to have tabletops count as a fire drill, as long as half of them were actual Evacuation Fire Drills.

A: No, table top exercises, while they can be very helpful in the planning phase, are not an acceptable substitute in lieu of actually performing the fire drill. The reason why is you are required to perform multiple functions during a fire drill:

  • Evaluate staff’s response to a fire situation, both at the point of the alarm and away from the point of the alarm
  • Evaluate the building’s response to the fire alarm
  • Evaluate the fire alarm’s response to the drill
  • Confirm that the alarm signal was transmitted to the fire department during the drill

In short: How are you going to confirm and evaluate all of that if you do not perform the drill?

Actual fire emergencies are usually an acceptable substitute in performing a fire drill, provided you still are able to make all of the evaluation and confirmations. However, that is not easy to do when you and your staff are responding to an actual alarm.

Sorry, but you still must perform the required amount of fire drills in your facility. And by the way, many accreditation organizations have changed the way they define time. The phrase ‘quarterly’ used to mean you could perform the fire drill anytime during the calendar quarter. Now, Joint Commission and HFAP will require you to perform a fire drill 3 months from the previous drill, plus or minus 10 days. That will require more planning and organization on your part.


Sep 25 2015

Extra Fire Drills for ILSM

Category: Fire Drills,ILSM,Questions and AnswersBKeyes @ 12:00 am
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Q: Joint Commission standard LS.01.02.01, EP 11 requires the hospital to perform an additional fire drill during periods of Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction. This standard goes on to say that the need for additional fire drills is based on the criteria in the hospital’s ILSM policy. Let’s suppose that a hospital has deficiencies in the Life Safety Code that lasts only for two, three, four days or maybe even a week. Would the hospital still be required to perform an additional drill for such a short duration of Life Safety Code deficiency? What if the hospital’s Safety Committee decides to state that as part of their ILSM policy criteria, it won’t conduct an additional fire drill per shift per quarter unless the Life Safety Code deficiency lasts beyond a certain amount of time, say maybe a month. It seems to me that a Safety Officer would be on the hook for an additional drill per shift per quarter if ILSMs are only in place for a week is overkill and would serve only to further desensitize staff to its fire alarm system.

A: Joint Commission’s standard LS.01.02.01, EP 11 is not prescriptive, meaning they choose not to specify when the extra fire drill needs to start to compensate for a certain deficiency. They don’t even tell you which deficiency the extra fire drill is even required. That is left up to you to decided and state in your ILSM policy.

I tend to think like you, in that the extra fire drill per shift per quarter does not make sense for a short-term LSC deficiency. But when is a LSC deficiency short-term and when is it considered long term? Perhaps a better approach is to ask: “When will the extra fire drill per shift per quarter be required?” Once you decide when the extra fire drill is required, that should help you decide how soon you need to implement the extra fire drill.

When I was the Safety Officer at the hospital where I worked, I felt the extra fire drill was needed when an exit was obstructed or the access to an exit was obstructed. The reason I believed this, is when you do a fire drill one of the items you are assessing is that staff knows the proper way to evacuate patients (using simulated patients, of course). If the path is obstructed, they need to know the alternative path and be able to demonstrate that. The extra fire drill should assesse the staff’s knowledge on evacuation routes.

Some LSC deficiencies aren’t as obvious so you need to ask yourself “Should I conduct an extra fire drill for this deficiency?” for all of the possible scenarios of LSC deficiency that you could have. Set up a Q&A for all the potential LSC deficiencies that you may encounter at your hospital, then ask yourself is an extra fire drill necessary. Here is an example:

  • Failed fire dampers?                                                   I would say no.
  • Obstructed exit?                                                          I would say yes.
  • Unsealed penetrations in a fire/smoke barrier?          I would say no.
  • Fire alarm pull stations not working?                         I would say yes.
  • Smoke detectors not working?                                  I would say no.
  • Obstructed access to an exit?                                     I would say yes.
  • An inoperative fire pump?                                         I would say no.

Ask yourself: “Would the staff benefit from an extra fire drill if this feature of life safety was not working?” I would say obstructed exits, obstructed access to exits, and inoperative fire alarm pull stations are easy to say ‘yes’ to… but the others? I’m not so sure as I don’t think the staff would benefit from an extra fire drill for an inoperative fire pump, or a failed fire damper. The next question is: “When do I begin the extra fire drills?” Well, if you have defective pull stations or an obstructed exit, you are going to do education and awareness training to the staff affected by these deficiencies. The purpose of the extra fire drill is to assess the staff’s knowledge of these LSC deficiencies after you have conducted the education and training. So, what is reasonable for an obstructed exit? A month after the exit became obstructed? I would say not. Maybe a week after the exit becomes obstructed, but I would say not any more than a week. The sooner the better, as you (the Safety Officer) want to know for sure that the staff knows about the LSC deficiency and takes appropriate alternative action. But this is my opinion, and you need to take this to your Safety Committee and let them offer their suggestions before you finalize your policy. Document this assessment in the form of a matrix, spread sheet or a written narrative in your ILSM policy, and have your Safety Committee review it and approve it. Then the surveyor can only hold you to what your policy says you should do.

Just as a reminder… The extra fire drills for ILSM purposes need to be conducted in the area(s) affected by the LSC deficiency. That means if you have an obstructed exit discharge due to construction, you need to perform the extra fire drills in all areas affected by the deficiency. That may mean you are doing multiple extra fire drills per shift per quarter, until the LSC deficiency is resolved. Also, each fire drill needs to activate the building’s fire alarm system, but during the hours of 9:00 pm and 6:00 am you are not required to activate the audible signals on the fire alarm system.


Sep 14 2015

Fire Drill Observers

Category: Fire Drills,Questions and AnswersBKeyes @ 12:00 am
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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.


Jul 06 2015

Fire Drills at Offsite Blood Draw Locations

Category: Business Occupancy,Fire Drills,Questions and AnswersBKeyes @ 1:00 am
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Q: We were recently cited by a surveyor for not conducting annual fire drills at our offsite blood draw locations. I have reviewed the Life Safety Code for business occupancies and we have only 4 employees at these offsite locations, which is less than the 100-person threshold required by the LSC to conduct drills. These locations are rented inside commercial buildings. Do you think we have to conduct fire drills at these locations?

A: Yes I do, because your accreditation organization says you have to. I think the accreditation organization standard is very clear: “The hospital must conducts fire drills annually from the date of the last drill in all freestanding buildings classified as business occupancies and in which patients are seen or treated.”  The building you described sounds like a business occupancy, and the act of drawing blood from a patient is certainly ‘treatment’. So, they got you from two different angles. I would agree with the surveyor that a fire drill should have been conducted annually at the draw stations, regardless of their size or number of employees. This is an example where the accreditor’s standards over-ride the requirements of the Life Safety Code. It’s one disadvantage for the hospital having their own staff and quick draw station, rather than sub-contracting it out. The cost to manage the Environment of Care at these offsite locations is extensive, and probably wasn’t considered when the hospital opened them up. A fire drill is not an easy proposition at these types of small locations, situated within another building. The Life Safety Code requires the activation of the building’s fire alarm system whenever a fire drill is conducted. This would have to be coordinated with the building owner.


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