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 184.108.40.206.3 of NFPA 99-2012, which requires annual fire drills in operating rooms and surgical suite locations.