Mar 21 2016

OR Fire Drills

Category: BlogBKeyes @ 12:00 am

Q: We just had an accreditation survey and the surveyor cited us for not having a separate fire drill in the Operating Room Suite. I don’t see this in any code or standard.

A: You are correct in saying that there is no standard which requires a fire drill to be performed in the surgery department. However, there are circumstances where this would be expected, and a surveyor could cite you for not conducting a drill in the OR. Here are some situations that would lead a surveyor to believe a fire drill should be conducted in the operating rooms:

  • Surveyor preference. It is possible that the surveyor has a prejudice for fire drills in the Surgery department. If he/she failed to provide a reason why they cited this finding, then it may be presumed they just did so, because they think it should be done; not because it needs to be done. The surveyor needs to say why a fire drill is needed in the Surgery department.
  • Previous history. If there has been a historical event in your Surgery department (such as a fire during a surgical procedure), then it is a reasonable expectation by the surveyor that you address this issue with fire drills. However, if this is the case, the surveyor needs to state the reason why they are citing you for not conducting fire drills in the Surgery department.
  • Lack of documented response during fire drills. According to accreditation standards, staff must participate in fire drills. This does not mean that a fire drill must be conducted in every unit in the hospital, as staff on the 1st floor may participate in a drill conducted on the 4th floor, as long as the building’s fire alarm system was activated. If the source of the alarm was on the 4th floor, staff on the 1st floor are still expected to participate, by closing doors, and preparing to receive evacuated patients. In many hospitals the expectation is to suspend the start of surgeries during a fire alarm until the ‘all-clear’ signal is given. The way to document that all staff participate in fire drills is to have observers on select units and floors to document what the staff did. If you have no documentation that someone observed how the staff in Surgery responded to the alarm, then I can see where the surveyor may have a legitimate concern for a finding.

If in fact you do have documentation that observed the Surgery staff’s response during a fire drill, then that should qualify as participating in a drill.

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Mar 07 2016

Fire Drills in Sleep Labs

Category: BlogBKeyes @ 12:00 am

Q: For an EEG sleep testing unit with an overnight stay in a business occupancy, are fire drills required quarterly or annually ?

A: Annually. The frequency of fire drills is determined on the occupancy designation of the facility, and chapter 38/39.7.1 of the 2000 Life Safety Code says fire drills are required to be conducted ‘periodically’. If you are Joint Commission accredited, they will expect annual fire drills, as would most any other authorities having jurisdiction. What may have you concerned is the term ‘sleeping rooms’ for the Sleep Lab. These are not sleeping accommodation rooms, so Hotel and Dormitory occupancy is not the correct designation for occupancy, as they would require quarterly fire drills. The Sleep Lab ‘sleeping rooms’ are actually exam rooms, which are monitored closely by staff all the time the patient is sleeping. The Sleep Lab is considered an out-patient service, and since there are no sleeping accommodation rooms, it can be designated as business occupancy, which allows for annual fire drills. Now, if you want to upgrade the occupancy designation to Hotels and Dormitories, then feel free to do so. But there will be more than just additional fire drills to contend with, and I would not recommend it.

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Dec 14 2015

Offsite Fire Drills

Category: BlogBKeyes @ 12:00 am

Q: We have a building that is a business occupancy with the exception of two ambulatory care units. I know we have to do fire drills four times a year because of this. One of the ambulatory care units is on the second floor and the other unit is on the main floor in a different wing. If we drill a location other than one of the ambulatory care units, do we need to have someone at each ambulatory care unit also? Or if we drill one ACU do we also need someone at the other one? And do we just observe the staff, or we required to ask the staff all the fire drill questions each time? We are Joint Commission accredited.

A: According to the accreditor’s standard EC.02.03.03, EP 4, it requires staff who work in buildings where patients are housed or treated to participate in drills according to the hospital’s fire response plan. Here is what that EP means:

  • The building that you mentioned is a combination business occupancy and ambulatory care occupancy, therefore it qualifies as a building that treats patients, and this EP applies.
  • The EP only requires staff to participate in fire drills according to what your fire response plan says they should do in the event of a fire. So, they should do something, depending on whether or not the source of the alarm is in their area or not.
  • If the source of the alarm is in their area, then they must follow your fire response plan, which is often referred to as R.A.C.E. That means they must rescue anyone in harm’s way; activate the alarm; close the doors; and extinguish or evacuate, depending what your plan says. If the source of the alarm is not in their area, then they probably just close the doors, which is part of the fire response plan, too.
  • How are you going to ensure your staff participated according to your fire response if you do not have someone observing them? You can post observers in various compartments to watch the staff’s response, the building’s response and the fire alarm system’s response. But, there are other methods, such as self-observation, which requires a manager or supervisor to fax in a report that self-analyzes their level of participation. I’m not a big fan of self-analysis, as they tend to forget to send in the fax and they often times embellish their report.
  • Keep in mind there is no direct requirement to have observers in various departments during fire drills. There used to be, but that standard was removed years ago. But the question a surveyor may ask is how do you know that your staff is participating? This can be done via spot checks, and self-reporting, or posting a couple observers in various departments, and move them around so you catch all departments in a 12 month period.

So, the bottom line is… Yes, you have to have some sort of observation to ensure staff participated in the drill, but the standard does not dictate how many departments need to be observed or how often. That is left up to you to decide. Also, Joint Commission’s hospital standards apply in offsite locations where hospital departments are located, even if those offsite departments are not healthcare occupancies.


Apr 30 2015

Fire Drills in an ASC

Category: BlogBKeyes @ 1:00 am

images0XCM788RI spoke at an Infection Control conference last week in St Louis, sponsored by the Excellentia Advisory Group. There were 13 different presentations made but mine was the only one that was not traditionally an IC subject matter. I was asked to make a presentation on how the Life Safety Code relates to Infection Prevention in the Ambulatory Surgical Centers. At first, I was reluctant to accept this speaking engagement because I was not sure how I was going to draw the connection between compliance with the Life Safety Code and how it actually impacts the Infection Prevention program in an ASC. But, I did accept the invitation and I researched the LSC and came up with a what I think was an interesting presentation.

Keep in mind, my audience was a room full of RNs who typically do not have any Life Safety Code compliance experience. So, I decided to take the approach that compliance with the LSC is just basic patient safety compliance, and identified many of the requirements that surveyors would be looking for.

At the end of my presentation I had time to take a few questions. One lady asked if they had to activate the building fire alarm system when they conducted a fire drill. I replied that yes, technically they would, since section of the 2012 LSC requires it. They said that is a problem since the ASC shares the building with other tenants who are not part of their healthcare network.

I replied that they had a few of options: 1) They could coordinate with all of the other tenants prior to the fire drill alerting them of the pending alarm. The other tenants could conduct their own drill at that time if they chose; or 2) They could investigate to see if the fire alarm control panel can bypass the occupant notification appliances in the other tenants during their drill; or 3) They could conduct a risk assessment that identifies the hardship involved in sounding the building fire alarm system and conduct the drill without activating the alarm. This would have to be reviewed and approved by the ASC safety committee, and possibly a surveyor would accept that.

I asked if they thought they could use one of those scenarios, and they thought #3 would be the only possible solution. I asked why, and they said there was a massage parlor directly above their ASC and they didn’t believe they could get the cooperation from them and all the other tenants so they could activate the fire alarm system when they conducted a fire drill each quarter. I replied that I thought they had a pretty good case for a risk assessment since nobody wanted to see clients from the massage parlor escaping down the stairs during a fire alarm.

Uhm… the strange things I see (or don’t see) in this business.

All-in-all, I thoroughly enjoyed my day at the conference and I got to meet many interesting people.

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Nov 13 2014

Use of Fire and Smoke Doors During a Fire Drill

Category: BlogBKeyes @ 6:00 am


I was recently asked if the Life Safety Code addresses the use of smoke and fire doors during a fire drill. Here is what I responded with:

The Life Safety Code (LSC) does address certain key actions required by staff during a fire drill, but it does not specifically restrict the use of doors in fire or smoke compartment barriers while the fire alarm is activated. Section 18/ of the 2000 LSC requires the healthcare occupancy to have a written plan for the protection of all persons in the event of a fire; for the evacuation to areas of refuge; and for the evacuation of the building when necessary. Section 4.7 of the same code also makes similar statements regarding orderly evacuation during a fire drill. It makes sense that opening and closing doors in a fire or smoke compartment barrier would be necessary in order to evacuate patients to another smoke compartment, or to evacuate the building. It also makes sense that responding emergency personnel (both internal and external) would have to open and close doors in order to assist with the evacuation or address the fire.

But perhaps what you are referring to is the action of the people who are not responding to the fire alarm, and they are going about their regular activity. Doctors, nurses, technicians, visitors, volunteers, vendors, and others may be ignoring the fire alarm and just continue to walk through doors to other parts of the building. These may be the people who you are referring to that are opening and closing fire and smoke compartment barriers doors during a fire alarm.

The Joint Commission standard EC.02.03.03, EP 4 says staff who work in buildings where patients are housed or treated participate in drills according to the hospital’s fire response plan. This is a little bit more than is required by section 18/ of the 2000 LSC, which says employees of healthcare occupancies shall be instructed in life safety procedures and devices. A fire drill is certainly one method of instruction in life safety procedures and devices. But neither the Joint Commission standards (and EP) and the LSC reference actually requires all staff to participate in every fire drill. It just wouldn’t be practical in a healthcare facility that is providing treatment and care to patients.

Therefore, hospitals get to decide for themselves how their staff should react during a fire alarm, as stipulated in their fire response plan (also known as the Fire Safety Management Plan). Most hospitals that I have had the pleasure of working with require staff in the immediate area of the fire emergency respond by following R.A.C.E. (Rescue; Alarm; Contain; and Evacuate or Extinguish) and staff away from the origin of the alarm simply close doors and be ready to receive patients. Some hospitals have staff away from the origin of the alarm to dispatch one individual with a fire extinguisher to the scene of the alarm.

You can write into your plan what you want your staff to do. If you want them to stop at each closed door and not traverse through it until the ‘all-clear’ is given, that is your decision, but I don’t think that is a very practical idea, or one that would be followed. When a fire alarm is activated, it represents a potential disaster and even though it may seem that a ‘all-hands-on-deck’ call is needed, that is not the practical thing to do as a first response. If your facility has 1200 workers on the average day shift, and the fire alarm is activated in the 4th floor ICU, you do not want all 1200 workers to rush up to the 4th floor ICU; that is not practical.

The concept of fire response in a healthcare occupancy is all healthcare workers are trained in the facility’s fire response plan. You count on the staff in the immediate vicinity of the fire to respond appropriately and quickly. Once the alarm is announced, certain trained individuals rush to the area where the alarm originates. The rest of the staff is supposed to reply in accordance with your fire response plan. Quite honestly, unless the staff has specific duties during a fire alarm, moving about the hospital performing their normal duties in areas away from the alarm would be considered appropriate. You actually need the hospital to continue to function even during a fire drill. Each fire drill will not asses every staff member’s response; it just is not practical in such a large setting. That is one reason why there are so many fire drills in a hospital each year: By sheer quantity you hope to get nearly all of the staff to participate in at least one drill.

Another issue is physicians. What should they do during a fire alarm? Many hospitals are writing into their fire response plan that physicians on a nursing unit that are not actively providing care or treatment to a patient, should report to the nurse’s station and await direction. In a Surgery department, unless the operating room is the scene of the fire, you pretty much want surgeons and nurses to remain in the operating rooms and continue with the business at hand, and wait for further instructions from the surgery nurse’s station.

I don’t know if I’ve helped you with your question, but if it were me, I would let people do what they normally do, unless they have specific responsibilities during a fire alarm. If you are really concerned about certain fire or smoke compartment barrier doors being opened in close proximity to a fire, then it would be practical to station one person at the door preventing unauthorized individuals from opening that door.

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Feb 06 2014

Fire Drill Devices

Category: BlogBKeyes @ 6:00 am

Fire Drill PictureTake a look at the picture to the left. Here is a container sitting on top of a desk, and it appears to be on fire. Only it is not an actual fire, but a simulated fire using lights, fans and silk. Pretty real looking, isn’t?

Jeff Clouse, the Safety Officer at Baptist Health in Lexington, KY sent me that photo with the following statement:

“For those hours between 9:00 PM and 6:00 AM when I use alternate forms of notification for fire drills, I bought this device. It is a ‘fake fire’ consisting of a metal box housing, some colored lights, two small yet powerful fans and a short length of silk.  You can see the effect in the picture; employees love it and it gives me a way to more positively interact with staff members during second and third shift drills.  Sometimes I’ll set this up in an empty patient room during first shift, close the door then tell an employee I have a question about something in this room.  They then see the fake fire and I proceed to have this employee walk through our response procedure and pull the alarm.  I then observe the other employees for their response proficiency.  It’s much more engaging then a plastic fire model or red tablecloth, etc.  I just had to have this thing.”

Can you imagine the expression on the face of the employee when they first see that? I bet Jeff gets much better participation and attention during his drills than used to when he did not use this ‘fake fire’. Thanks for sharing, Jeff.

Does anyone else have a picture of a device they like to use during their fire drills?



Sep 26 2013

Woman dies during mock fire drill in Bangalore

Category: BlogBKeyes @ 5:00 am
Published February 24, 2012 in “The Hindu” newspaper:
A fire drill at a garment factory went horribly wrong on Friday when a rope snapped sending a woman employee plummeting to her death from a height of nearly 15 meters.According to eyewitnesses, C.R. Nalina (24), a Senior Welfare Officer at Bombay Rayon Fashions Ltd. in Yeshwanthpur, fell head first onto the concrete floor below. Co-workers rushed her to a hospital in Krishnanagar but it refused to treat her. She was then moved to another hospital in Basaveshwarnagar where efforts to revive her failed.Co-workers said the event began at 10.30 a.m. with a few presentations and speeches. At 11 a.m. the entire premises was evacuated and the employees gathered outside to watch the drill.

Around 11.30 a.m., personnel from the Fire and Emergency Services proceeded to demonstrate one of their more eye-catching maneuvers. The move involved lowering a person from a height using a rope harness.

First a man was lowered and landed safely. When the fire personnel called for another volunteer, most people backed out but Ms. Nalina stepped up to the challenge.

“She probably felt that as a person responsible for employee welfare, she should set an example,” said one employee. She was put on a harness and lowered from the fourth floor window. “The rope snapped when she was nearing the second floor,” said Regional Fire Officer J.H. Ravishankar, who was on the spot.

Fire personnel initially told The Hindu that the rope used in the maneuver was a brand new one and made of nylon. But when the blood-soaked rope was brought to the hospital where the post-mortem was conducted, it became amply clear that it was not made of nylon. It also looked fairly old and worn out. A safety net was also not used during the drill.

A fireman who has spent over 20 years in the department said that a live model should never have been used for the demonstration.


Obviously, no one associated with healthcare would attempt a fire drill by lowering someone from a window using a rope and harness. But this article raises awareness that conducting drills for evacuation during a fire are serious issues, that need to be carefully planned and implemented.

I remember being part of a fire evacuation drill early in my career where mock patients were evacuated down the stairs using fire-mans carry. Some of us were not up to the task and dropped our mock patients during the evacuation. Also, old mattresses were used to slide mock patients down the stairs. That ended up with a few volunteers with bumps and bruises. After that event, we never did another evacuation drill.

But it is important to plan and then drill evacuation methods. As a consultant, I frequently see the newer style evacuation chairs stashed in or near the stairwells. I ask staff if they have ever been trained on how to use the evacuation chairs, and often times I hear that they have not. When there is a fire and there is a need to evacuate the patients down the stairs, that is not the time to learn how to use the evacuation chairs.



Dec 13 2012

Fire Drills in Offsite Patient Care Locations

Category: BlogBKeyes @ 6:00 am

Here is a scenario: A hospital has multiple ‘quick draw’ blood stations scattered across the community in which they are located. These blood draw stations are situated in other occupancies, and strategically located in shopping malls and other high-traffic areas for the convenience of their patients. Hospital staff occupy and manage these blood draw stations, although the actual area is approximately 250 square feet, or the size of an average patient room in a hospital.

The hospital failed to conduct fire drills in these blood draw stations because they did not feel they qualified since they were so small in size. A Joint Commission surveyor discovered the fact that fire drills were not conducted and wrote them up for failure to do fire drills in an offsite business occupancy environment.

I think the finding is valid as the TJC standard EC.02.03.03, EP 2 is very clear: “The hospital conducts fire drills every 12 months from the date of the last drill in all freestanding buildings classified as business occupancies and in which patients are seen or treated.”  The situation described sounds like a business occupancy to me, and the act of drawing blood from a patient is certainly ‘treatment’. So, they got hit 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. It’s one disadvantage for the hospital having their own staff and quick draw station, rather than sub-contracting it out. They also have to do annual emergency response drills at these locations as well, which really doesn’t amount to much at all. In addition, all of the 6 EOC management plans have to apply to these quick draw stations and, the SOC Basic Building Information (BBI) has to list these locations as well. The cost to ‘manage’ the Environment of Care at these offsite locations is extensive, and probably wasn’t considered when they wanted to open them up.  The organization has to manage these locations in a similar way they would manage a clinic.

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 alarm is conducted. This would have to be coordinated with the building owner.

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