Fire Drills in a High-Rise Hospital

Q: A question was brought up today about whether or not what we are doing for fire drills meets code. Currently, as a high-rise hospital (12 floors), we are conducting drills 1 per shift per quarter, so 3 drills per quarter. Each drill affects 3 floors, the floor of activation, the floor above, and the floor below. Does activating only 3 floors per drill meet the intent of code, or should we be performing drills 3 times a quarter for the entire tower? This would equate to 12 drills in all per quarter.

A: According to the 2012 LSC, section 19.7.1.6, drills are conducted quarterly on all shifts to familiarize staff with the signals and emergency action required. These drills must be conducted under varied conditions.

Section 4.7.2 says fire drills are held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills must include suitable procedures to ensure that all persons subject to the drill participate.

So, the intent of the fire drill is to help staff become familiar with the fire alarm signals and the emergency action required. And, drills must ensure that all persons (i.e. staff) participate in the drill. Under your current practice, how does your staff on the 2nd floor participate in the fire drill is it is initiated on the 8th floor? It appears that they cannot, since you are only activating the occupant notification signals on the 7th, 8th, and 9th floors.

I fully understand compartmentalizing the fire alarm signals to the floor where the alarm is initiated, the floor above and the floor below. This is permitted in NFPA 72-2010. However, by doing so, you are unknowingly violating the Life Safety Code, because you are preventing ¾ of the rest of the staff from participating. So, compartmentalizing the alarm signal on an actual fire alarm is permitted, but I don’t see where doing so is permitted for fire drills.

Now, one may ask what the 2nd floor staff should do if the alarm is initiated on the 8th floor? While it is understood there is not a lot to do, there is basic fire response procedures that must be followed:

  • Close all doors
  • Clear corridors of clutter
  • Be prepared to receive evacuating patients from other floors
  • Send staff to scene of fire with extinguishers (if that is part of your fire plan).

Evacuation During a Fire

Q: We are a hospital and if there was a fire, say at the northeast part of the building does everyone throughout the whole building have to evacuate the building or only the ones on that side of the building? Same thing with fire drills; does everyone have to evacuate?

A: No… Everyone does not have to evacuate. You never want to evacuate the building unless it is absolutely necessary. Evacuation should always be horizontal and local. This means if 4 west has a fire, then the occupants on 4 west evacuate to 4 east, (or 4 north, or 4 south). You do not take patients down the stairs unless it is absolutely necessary. If you do have to evacuate vertically, you use an elevator that is not actively involved with the fire to evacuate the patients. Forget all those signs that say “In Case of Fire – Use Stairs”. That does not apply to evacuating patients. The Life Safety Code actually says it is permissible and recommended that you use elevators in the evacuation of patients, as long as the elevator is not actively involved in the fire.

For fire drills, you use simulated patients (put a staff member in a wheelchair and observe the other staff members push the wheelchair to an adjoining smoke compartment). You must observe that they did evacuate a simulated patient to the adjoining (horizontal) smoke compartment. That is why it is important to identify which set of cross-corridor doors are smoke barriers.

Weekend Fire Drills

Q: Do you know anything about fire drills on weekends? What is the requirement?

A: Section 19.7.1.6 of the 2012 LSC says fire drills must be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency action required, under varied conditions.

The accreditation organizations (AOs) have standards that say similar things. The term ‘under varied conditions’ is used to mean not only different scenarios are used for fire drills, but the fire drills are conducted in different locations, at different times (up to 2-hours different start time for same-shift drills), and on different days of the week. This is often interpreted by the AOs to mean fire drills must include the weekend and holiday shift personnel.

You will not find a specific standard in the CMS Conditions of Participation, or the AOs manual that states fire drills must be conducted on weekends and holidays, but the expectation of the surveyors is you will. If you fail to include those workers, then you are not conducting drills under ‘varied conditions’.

Fire Drills in a Hospital

Q: I work in a hospital. When we conduct our routine scheduled fire drills are we required to actually activate the fire alarm pull station, horns or strobes? Are we required, during a fire drill, to check that a signal was sent from our facility to the fire department/alarm company? This could be problematic as horns and strobes are very disruptive. We test these functions during the alarm testing but we have not been activating the alarms during fire drills. Should our procedures be changed?

A: Yes… All of the occupant notification devices (i.e. horns, chimes, strobes, bells, whistle, etc.) MUST be activated during all fire drills, with the exception of those drills conducted during the hours from 9:00 pm to 6:00 am. During the evening hours, a coded announcement may be used in lieu of activating the audible devices. Section 19.7.1.4 of the 2012 LSC is very clear… Fire drills in healthcare occupancies must include the transmission of a fire alarm signal and simulation of emergency fire conditions. Section 19.7.1.6 continues to say fire drills must be conducted quarterly on every shift to familiarize staff with the signals and emergency action required under varied conditions.

The purpose of a fire drill is multi-fold:

  • For staff to become familiar with the emergency process
  • To evaluate the staff’s response to the fire alarm signal
  • To evaluate the building’s response to the fire alarm signal
  • To evaluate the fire alarm system’s response

Section 19.7.1.2 says all employees must be periodically instructed and kept informed with respect to their duties under the fire response plan. This is accomplished by conducting fire drills, and then having trained observers in certain locations of the hospital to evaluate the staff’s response.

Some accreditation organizations have specific standards that requires all staff to participate in every drill in accordance with the hospital’s fire safety plan. This means if the fire alarm is initiated on the 4th floor, what do you expect staff to do on the 1st floor? Basically, they need to close their doors and be prepared to receive evacuated patients from the 4th floor. How do you know if the staff did this on the 1st floor if you don’t have observers watching for it?

Yes… horns and strobes can be disruptive… That’s the whole idea of a fire alarm notification system: To disrupt the normal activity and alert everyone that there is a fire emergency. Routine fire drills should be anything but routine. Every hospital should take fires seriously and be prepared for the unfortunate event should it ever occur. Therefore, fire drills are the utmost importance, and everyone (as much as practical) should participate in each drill. Don’t forget that one of the purposes of the fire drill is to educate staff on the emergency process. That is why the Life Safety Code requires so many each year.

No… there is no requirement to ensure the fire alarm signal is received at the local fire department for each fire drill.

Fire Alarm Activation for Fire Drills in Business Occupancies

Q: I’m responsible for doing annual fire drills in our blood draw stations located throughout several communities. Some are in physician’s offices and some are in office buildings. I can find nothing in NFPA 101, 2012: 4.7 or in 38 or 39 New or Existing Business Occupancy. Can you help with the code requiring alarm activation?

A: Well… according to NFPA Life Safety Code, there are no requirements to activate the fire alarm system during a drill for business occupancies. Where the confusion comes into play, most accreditation organizations requires sub-stations of hospital departments to follow the hospital requirements regarding operations. The healthcare occupancy chapter requires activation of the fire alarm system for fire drills, and some surveyors likely require the same for any offsite department that is an extension of the hospital to comply. If they are requiring the fire alarm system to be activated during a fire drill for a blood draw station located in a business occupancy, that would be a mistake by my opinion. This is an easy mistake for a surveyor to make, as all other aspects of the blood draw station must comply with the hospital’s policies and procedures if it is an extension of the hospital department. So, I can see how a surveyor could expect the fire alarm system to be activated for a fire drill in an offsite blood draw station.

Operating Room Fire Drills

Q: Back in March 2016, you answered a reader’s question that fire drills are not specifically required for operating rooms. While reviewing NFPA 99-2012, I came across a section that states that fire exit drills must be conducted annually or more frequently as determined by the applicable building code, Life Safety Code, or fire code. Does this mean we must conduct fire drills in each of our operating suites every year?

A: Your observations are excellent. Back in March, 2016, there were no requirements to conduct a fire drill in Surgery. Now, after CMS adopted the 2012 edition of NFPA 99, there is. As you pointed out, section 15.13.3.10.3 of NFPA 99-2012, does require an annual fire drill for the operating room and surgical suite personnel.

However, the code does not say a fire drill has to be conducted in each operating room. The purpose of a fire drill in surgery is to provide education and training for staff. Therefore, my suggestion is to schedule the annual fire drill when there are no scheduled surgeries, and as many staff as possible can attend. You begin by conducting an education session on what the expectations are if a fire was discovered in the operating room. You can have different scenarios as the circumstances dictate. Then conduct a drill to see if the staff performs satisfactorily. If you have lots of staff, then utilize multiple operating rooms, and have multiple observers.

Business Occupancy Fire Drills

Q: For clinics that are listed as business occupancies is there a requirement to activate the fire alarm system (chimes and strobes) and send a signal to a third party during a routine fire drill? We have documented staff participation with each drill. The building fire alarm system including communication with the third party is also completed during the year per standard. The clinic (business occupancy) may be located in a building with many other types of businesses.

A: I don’t think so. If you look at the healthcare occupancy chapter section 18/19.7.1.4 (2012 LSC), it says fire drills shall include the transmission of the fire alarm signal. However, there is no comparative section in chapters 38 & 39 for business occupancy. Since the business occupancy chapter does not specifically require the activation of the building fire alarm system for a fire drill, then I would say it is not a Life Safety Code requirement. It would be best practice, but not a requirement.

Sections 38/39.7.2 (2012 LSC) says fire drills in business occupancies (where required) must comply with section 4.7. Section 4.7 discusses many requirements regarding fire drills but activating the fire alarm system is not one of them. Please review your accreditation standards to determine if they require activation of the fire alarm system during a fire drill in a business occupancy.

Offsite Fire Drills

Q: Our hospital has several “out buildings” or offsite Doctor’s offices. Are we required to do fire drills at these offices? Three of our buildings have fire alarm systems that are tested semi-annually. But we weren’t sure if we were supposed to conducting fire drills at these doctor’s offices or how often they need to be done to be in compliance?

A: Generally, yes… fire drills are required once per shift per year at offsite business occupancies, but it has much to do with your accreditor, or any other authority who enforces the Life Safety Code. Physician’s offices are typically classified as business occupancies and section 39.7.2 of the 2012 LSC says fire drills are only required in business occupancies where the building is occupied by more than 500 persons, or if there is more than 100 persons above or below the street level. So, from a LSC stand point there may be an exception to not conduct fire drills if your physician’s offices are under the 500/100 person threshold.

However, you still have to consider what your accreditation organization requires. For instance, Joint Commission standard EC.02.03.03, EP 2 requires annual fire drills in all business occupancies. Other accreditation organizations, state agencies and local municipalities may have the same requirement. So, it is likely that you do have to conduct annual fire drills.

Fire Drills in Operating Rooms

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.

Fire Drills for Off-Site Locations

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.