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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Q: I am new to this position and I am working on updating my management plan on fire safety. Currently it states “The fire department’s Fire Prevention Bureau will conduct at least two fire drills annually”. Is it a requirement to have the local fire department participate in two of our fire drills, annually?
A: No, it is not. The accreditation organizations and CMS do not have standards that require the local fire department to participate in the healthcare organization fire drills. The Life Safety Code and the other NFPA standards do not as well. It may be possible that there is a local or state regulation that requires the involvement of the local fire department in your drills, but there is no accreditation or certification requirement to do so. However, having the local fire department present during fire drills can be a good thing as it creates positive interaction with them. You can never have too much good will with the local fire inspector and his department. But if it is not required, and it becomes a burden to continue to involve them, take it to your Safety Committee and discuss the issue with them. Ask them if it is okay to stop including the local fire department, and see what they think.
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Q: Do we have to conduct a fire drill in every department and unit at least once per shift per quarter throughout our hospital? Some staff is telling me that unless we do so, we are not meeting the Joint Commission requirement for fire drills. Is this true?
A: No, you do not. This is a frequently misunderstood aspect of the Joint Commission standard EC.02.03.03. The performance elements of this standard say fire drills must be conducted once per shift per quarter in each building (not each unit) that is defined as a healthcare occupancy. Where the misunderstanding comes in is the requirement for staff to participate in fire drills in buildings where patients are housed or treated, in accordance with the hospital’s fire response plan. At the source of the fire alarm staff has multiple requirements, but on units and floors away from the origin of the fire, there is little for staff to do other than close doors and be on alert. You may ‘spot-check’ your staff’s participation on units away from the origin of the alarm by having observers make note of the staff’s reaction. These observers may be individuals from your safety committee, or they may be managers of their respective departments.
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Q: How would you define unannounced when it comes to fire drills? There doesn’t appear to be anything in the standard that explains what this means. What do you say?
A: The standard you are referring to is the Joint Commission Environment of Care standard, which limits unannounced drills to no more than 50% of all drills. This is not a life safety issue as the Life Safety Code does not address it. In lieu of asking Joint Commission what they meant, I would define announced fire drills as having a published schedule of future drills which is shared with others. Another example of announced drills is having the switchboard operators announce overhead “This is a drill” when the fire alarm is activated. The reason announced drills are undesirable, is staff will react less than optimally when they know the fire alarm is only a drill.
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Q: Are we required to conduct fire drills on every unit and in every department once per quarter per shift in our hospital? Are we required to make sure everyone in the hospital participates in the drill? We have some engineering managers at our hospital who say we must conduct fire drills on every unit once per shift per quarter. That can mean over 300 fire drills per year for us.
A: No and Yes. No, you do not have to conduct fire drills on every unit in the hospital per quarter per shift, and yes, staff is expected to participate in the drills. Allow me to explain: Section 220.127.116.11 of the 2000 edition of the Life Safety Code (LSC) says fire drills must be conducted in hospitals, quarterly on each shift. It does not say anything about drills that must be conducted quarterly on each shift for each department. Section 18.104.22.168 goes on to say drills are conducted to familiarize personnel (such as nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions. That is another way of saying staff must participate in the drills. Joint Commission (and other accrediting organizations) has similar language in their standards found in EC.02.03.03. Where people sometimes become confused, is in the language that requires everyone to participate. Well, for the most part, everyone does participate (or should participate) every time there is a fire drill. Those closest to the area where the alarm is initiated follow the acronym for the hospital’s fire plan, which is frequently R.A.C.E. They Rescue, Active the alarm, Confine, and Extinguish (or Evacuate). But those individuals away from the area where the alarm is initiated also participate, but usually the only requirement in R.A.C.E is to Confine the area by closing the doors. Your organization may have other fire response plans for those individuals to respond to the scene of the alarm with a fire extinguisher. So, everyone on that shift participates (supposedly) in one single fire drill, and you can confirm their participation by having observers in strategic areas making sure they closed the doors.
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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 22.214.171.124 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.
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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 18/126.96.36.199). 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.
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