May 14 2018

Fire Drills in a Hospital

Category: BlogBKeyes @ 12:00 am
Share

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.

Tags:


Mar 07 2018

Fire Alarm Activation for Fire Drills in Business Occupancies

Category: BlogBKeyes @ 12:00 am
Share

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.

Tags: ,


Feb 12 2018

Operating Room Fire Drills

Category: BlogBKeyes @ 12:00 am
Share

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.

Tags: ,


Jun 30 2017

Fire Drill Response

Category: BlogBKeyes @ 12:00 am
Share

A recent question by a reader asked if fire-rated doors and smoke compartment barrier doors that close on a fire alarm could be opened before the fire alarm is considered ‘all clear’. 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 18/19.7.1.1 of the 2012 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 codes 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 the reader was 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 the reader was 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 18/19.7.1.2 of the 2012 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 standard (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. Business must continue even during a fire alarm, so some staff must continue with their assigned responsibilities.

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 an ‘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 the reader with his 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 the reader is 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.

Tags:


Mar 21 2016

OR Fire Drills

Category: BlogBKeyes @ 12:00 am
Share

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.

Tags: ,


Mar 07 2016

Fire Drills in Sleep Labs

Category: BlogBKeyes @ 12:00 am
Share

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.

Tags: ,


Dec 14 2015

Offsite Fire Drills

Category: BlogBKeyes @ 12:00 am
Share

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.

Tags:


Apr 30 2015

Fire Drills in an ASC

Category: BlogBKeyes @ 1:00 am
Share

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 20.7.1.4 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.

Tags: , ,


Nov 13 2014

Use of Fire and Smoke Doors During a Fire Drill

Category: BlogBKeyes @ 6:00 am
Share

imagesVOC6UHJ4

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 18/19.7.1.1 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 18/19.7.1.3 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.

Tags: , ,


Feb 06 2014

Fire Drill Devices

Category: BlogBKeyes @ 6:00 am
Share

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?

 

Tags:


Next Page »