False Alarm Fire Drills

Q: Can accidental fire alarm activations, such as burnt popcorn, be counted toward a quarterly fire drill requirement if documentation of staff response is received in regard to said accidental activation?

A: I would think so. A long as you evaluated the staff’s response; the building’s response; and the fire alarm system’s response, I would believe a false alarm activation of the fire alarm system could be considered the same as a fire drill.

Fire Drills in the Behavioral Health Unit

Q: I work at a hospital that has just partnered with a Behavioral Health organization. We have renovated a floor and will be opening up soon. My question is this: For fire drills in the main hospital, I am sure it would be best to separate these activities from the Behavioral Health unit. And I am sure we would need to be notified on our panel if an event happened on the unit. Am I on the right track? Is there any code that speaks to this? In addition, what would be your suggestions in regard to stairwell egress in the case of an alarm on the Behavioral Health unit. Delayed egress? Clinical needs locks?

 A: Okay… so there is a lot to cover here. As I understand your question, you will soon be opening a behavioral health unit in an existing acute-care hospital. You say you are partnering with another organization… does this mean the behavioral health unit is a separate entity (i.e. does it have a separate CMS certification number) from the acute-care hospital?

 If the behavioral health unit is a separate entity, then you must conduct separate fire drills (once per shift per quarter) in the behavioral health unit as compared to the rest of the acute-care hospital. If the behavioral health unit is not a separate entity, then you are not required to conduct separate fire drills from the rest of the acute-care hospital. So, you need to verify if the behavioral health unit will be a separate entity from the acute-care hospital.  

The fire alarm control system is a system for the entire building, even if there are separate entities inside the building. If a fire alarm originated on the behavioral health unit, you most definitely need to know about it in the acute-care hospital, and vice-versa.

The behavioral health unit would likely qualify for clinical needs locks as described in 18.2.2.2.5.1 of the 2012 LSC. These locks are not required to automatically unlock on activation of the fire alarm system. You can do that if you want, but there is no requirement to do so. Actually, you really don’t want the locks on the doors in the behavioral health unit to automatically unlock on a fire alarm, because patients will soon figure that out and will loiter around the locked egress doors and jump at the chance to elope whenever a fire alarm actuates. I do not suggest delayed egress locks, but rather clinical needs locks as long as you qualify for them.  

ILSM Fire Drills

Q: I’ve been conducting two fire drills per month while we are under construction. I am new to the safety role and my understanding of the code is that I should be doing 2 per quarter each on different shifts. My facilities guy says 2 per month. Who is correct? I think we are giving our employees alarm fatigue.

A: Fire drills must be conducted as follows for healthcare occupancies (i.e. hospitals) and ambulatory health care occupancies (i.e. ASC):

  • Regular fire drills must be conducted once per shift per quarter, with start times staggered by 2-hours on fire drills conducted on the same shift but on consecutive quarters;
  • ILSM fire drills must be conducted once per shift per quarter in areas affected by the impairment requiring the ILSM fire drill. This drill is in addition to the regular fire drill.

The ILSM fire drill must evaluate each departments response that is affected by the impairment that requires the ILSM fire drill. This may mean you will have more than one ILSM fire drill per shift per quarter.

It appears you are on the right track with 2 fire drills per shift per quarter while the construction is underway. I’m not sure where the facility guy is coming from with the 2 drills per month requirement.

Fire Drills

Q: There is a lot of confusion on how many fire drills we have to complete. We have 3 towers where there is healthcare, all connected, but different building names. Do we only need to complete 1 fire drill per shift per quarter in EACH building or can we combine the 3 towers into one healthcare? They are breaking out each tower and conducting the required amount in each building, which seems overkill.

A: The intent of the Life Safety Code is to conduct fire drills once per shift per quarter in all healthcare occupancies per building. If you have more than one building on campus that contains healthcare occupancies, then you would have to conduct separate fire drills for each shift and each quarter in each building.

However, if the buildings that contain healthcare occupancies are contiguous (connected together) and there is no fire rated barrier serving as a separation barrier between the buildings, then you could do one fire drill per shift per quarter that would cover all the buildings.

A separation barrier would be a fire-rated barrier that is vertically aligned (meaning the barrier does not extend horizontally) from the lowest floor to the roof. The fire rating of the barrier could differ depending on the applicable codes and standards, but the NFPA 101 Life Safety Code would require at a minimum a 2-hour fire rating.

Ambulatory Healthcare Occupancy Fire Drills

Q: My question is with an ambulatory healthcare occupancy classification. Do you need just one fire drill per quarter or do you need one fire drill per shift per quarter? The ambulatory healthcare occupancy has a 24hr ED and also has some departments that have three shifts, ie: EVS, Security and Medical Imaging.

A: According to section 21.7.1.6 of the 2012 Life Safety Code, fire drills are to be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and the emergency action required under varied conditions. So, the answer is once per shift per quarter.

Fire Drills

Q: Is it required to activate the fire alarm system in our hospital whenever a fire drill is conducted for AM or PM Shift?

A: Yes. According to section 19.7.1.4 of the 2012 Life Safety Code, fire drills in healthcare occupancies must include the transmission of a fire alarm signal and simulation of emergency fire conditions. The Annex explains that the purpose of the drill is to test and evaluate the efficiency, knowledge, and response of the healthcare personnel in implementing the emergency fire response plan. The purpose is to not excite or disturb the patients, so doors to patient rooms should be closed. Between the hours of 9pm and 6am, you still must activate the fire alarm system during a drill, but you have the option to silence any audible notification devices.

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).

Evacuation During a Fire

Q: We are a hospital and if there was a fire, say at the northeast part of the building does everyone throughout the whole building have to evacuate the building or only the ones on that side of the building? Same thing with fire drills; does everyone have to evacuate?

A: No… Everyone does not have to evacuate. You never want to evacuate the building unless it is absolutely necessary. Evacuation should always be horizontal and local. This means if 4 west has a fire, then the occupants on 4 west evacuate to 4 east, (or 4 north, or 4 south). You do not take patients down the stairs unless it is absolutely necessary. If you do have to evacuate vertically, you use an elevator that is not actively involved with the fire to evacuate the patients. Forget all those signs that say “In Case of Fire – Use Stairs”. That does not apply to evacuating patients. The Life Safety Code actually says it is permissible and recommended that you use elevators in the evacuation of patients, as long as the elevator is not actively involved in the fire.

For fire drills, you use simulated patients (put a staff member in a wheelchair and observe the other staff members push the wheelchair to an adjoining smoke compartment). You must observe that they did evacuate a simulated patient to the adjoining (horizontal) smoke compartment. That is why it is important to identify which set of cross-corridor doors are smoke barriers.

Weekend Fire Drills

Q: Do you know anything about fire drills on weekends? What is the requirement?

A: Section 19.7.1.6 of the 2012 LSC says fire drills must be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency action required, under varied conditions.

The accreditation organizations (AOs) have standards that say similar things. The term ‘under varied conditions’ is used to mean not only different scenarios are used for fire drills, but the fire drills are conducted in different locations, at different times (up to 2-hours different start time for same-shift drills), and on different days of the week. This is often interpreted by the AOs to mean fire drills must include the weekend and holiday shift personnel.

You will not find a specific standard in the CMS Conditions of Participation, or the AOs manual that states fire drills must be conducted on weekends and holidays, but the expectation of the surveyors is you will. If you fail to include those workers, then you are not conducting drills under ‘varied conditions’.

Fire Drills in a Hospital

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.