Fire Drills in Offsite Patient Care Locations

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.

Unannounced Fire Drills

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.

Fire Drill Participation

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 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 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.

Fire Alarm Activated During Fire Drills

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 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.

Fire Drills Performed on Every Unit

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/ 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.