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).