Fire Alarm Activation for Fire Drills in Business Occupancies

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.

Operating Room Fire Drills

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.

Business Occupancy Fire Drills

Q: For clinics that are listed as business occupancies is there a requirement to activate the fire alarm system (chimes and strobes) and send a signal to a third party during a routine fire drill? We have documented staff participation with each drill. The building fire alarm system including communication with the third party is also completed during the year per standard. The clinic (business occupancy) may be located in a building with many other types of businesses.

A: I don’t think so. If you look at the healthcare occupancy chapter section 18/19.7.1.4 (2012 LSC), it says fire drills shall include the transmission of the fire alarm signal. However, there is no comparative section in chapters 38 & 39 for business occupancy. Since the business occupancy chapter does not specifically require the activation of the building fire alarm system for a fire drill, then I would say it is not a Life Safety Code requirement. It would be best practice, but not a requirement.

Sections 38/39.7.2 (2012 LSC) says fire drills in business occupancies (where required) must comply with section 4.7. Section 4.7 discusses many requirements regarding fire drills but activating the fire alarm system is not one of them. Please review your accreditation standards to determine if they require activation of the fire alarm system during a fire drill in a business occupancy.

Offsite Fire Drills

Q: Our hospital has several “out buildings” or offsite Doctor’s offices. Are we required to do fire drills at these offices? Three of our buildings have fire alarm systems that are tested semi-annually. But we weren’t sure if we were supposed to conducting fire drills at these doctor’s offices or how often they need to be done to be in compliance?

A: Generally, yes… fire drills are required once per shift per year at offsite business occupancies, but it has much to do with your accreditor, or any other authority who enforces the Life Safety Code. Physician’s offices are typically classified as business occupancies and section 39.7.2 of the 2012 LSC says fire drills are only required in business occupancies where the building is occupied by more than 500 persons, or if there is more than 100 persons above or below the street level. So, from a LSC stand point there may be an exception to not conduct fire drills if your physician’s offices are under the 500/100 person threshold.

However, you still have to consider what your accreditation organization requires. For instance, Joint Commission standard EC.02.03.03, EP 2 requires annual fire drills in all business occupancies. Other accreditation organizations, state agencies and local municipalities may have the same requirement. So, it is likely that you do have to conduct annual fire drills.

Fire Drills in Operating Rooms

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

Fire Drills for Off-Site Locations

Q: I have a question that is still a little fuzzy regarding fire drills. My hospital is partners with a separate clinic. Several of the clinics throughout the community have hospital employees working there (PT, Imaging etc.) but the building is owned by the clinic. Who is responsible for running drills and testing the emergency operations plan? On a side note, some of the clinics are Rural Healthcare Clinics, so the hospital owns the clinic and it operates under the hospitals CMS number but all of the employees are clinic employees not hospital.

A: Yes… I could see where this would be a fuzzy issue for you. Here is how I suggest you address this issue:

  • Your hospital has an interest in the clinics
  • Your hospital has staff that work in the clinics
  • Your hospital has patients that receive care in these clinics

Therefore; you are responsible for all testing, inspecting, and maintenance of all the fire-safety equipment, and you’re responsible for all drills (EM and fire), as well as meeting the requirements for management plans, EOPs, and policies and procedures.

An AHJ will very likely determine that since you have staff and patients in these facilities, they must fall under the hospital’s rules/standards for Emergency Management, Physical Environment, and Life Safety. That means you need to have copies of the documentation that all of the fire-safety devices were tested and maintained, and copies of all drills were conducted.

Now… if you have a great relationship with your partner clinic, and they perform all of the testing and inspecting requirements, and the drill requirements, then that is fine. You can use copies of their reports as evidence of compliance. But you still need to include these clinics in your management plans and EOP scope of work.

The bottom line is… as long as you have staff and /or patients in these clinics, then your accreditor will very likely expect that you comply with all of the hospital standards at these off-site locations.

Unannounced Fire Drills

Q: Somewhere I read that at least 50% of fire drills had to be unannounced. I don’t find that requirement in NFPA Life Safety Code so it may have been a Joint Commission requirement. We use DNV now and announce very few of our drills but I would like to know if there is any such requirement.

A: You are correct in saying that Joint Commission has a standard on this issue, but the Life Safety Code also addresses this as well. Look at section 4.7.4 of the 2012 Life Safety Code. It says drills shall be held at expected and unexpected times to simulate the unusual conditions that can occur in an actual emergency. While this section does not state 50% of the drills have to be unannounced, the assumption is that unexpected equates to unannounced.

Actually, DNV standard PE.2, SR.6 says healthcare occupancies shall conduct unannounced fire drills. So, it appears DNV wants all their fire drills to be unannounced, not just 50% of them. So, it looks like you should be doing all of your fire drills as being unannounced.

Fire Drill Response

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.

Quarterly Fire Drills

Q: There is a matrix floating around on the web that describes Joint Commission’s compliance for fire drills. It breaks the quarters down as Q1=January, February, March, and Q2=April, May, June, etc. Does this mean that for a first shift drill last run in April, we can have the next drill run in September and still be compliant, + or – 10 days?

A: No, not for Joint Commission. In their Overview to the Environment of Care chapter in the Hospital Accreditation Standards manual, Joint Commission says quarterly or once per quarter means “every three months, plus or minus 10 days”. Now, I’ve heard Joint Commission engineers say they will allow this to be interpreted as follows: If the drill was conducted on April 15, that means three months from April is July. July plus 10 days means August 10 and July minus 10 days means June 20. So, according to the engineers from The Joint Commission, the window of opportunity is 51 days: from June 20 to August 10. That scenario would apply to any date the drill was conducted in April.

But to be honest, the Overview of the Joint Commission manual doesn’t say that. Other people are interpreting the Overview to mean if the drill was conducted on April 15, then 3 months after that is July 15. July 15 plus 10 days is July 25, and July 15 minus 10 days is July 5. That leaves you with a 20-day window of opportunity. 20 days is significantly less than 51 days, so you will be at the mercy of the surveyor to determine which one they enforce.

But in the past year, CMS has stated unofficially that they do not like any scenario that allows more than 3 months for a fire drill. In other words, they don’t mind the “every three months, minus 10 days”, but they don’t like the “every three months, plus 10 days”.

Quarterly Fire Drills

Q: We are required to conduct a fire drill every quarter. If I did one on March 22, when is the earliest and the latest dates that I can do the next one?

A: It depends on who your AHJ is. CMS would allow it to be conducted anytime during the quarter so the next drill could be done as soon April 1 or as late as June 30.

HFAP requires 3 months from the previous activity, with the next drill performed during the third month. So 3 months from March 22, is June 22, the 3rd month would be June, so the next fire drill should be conducted anytime in June.

Joint Commission requires 3 months from the previous activity plus or minus 10 days. But they have a different interpretation on how this is calculated: Three months from March 22, is June. Plus 10 days is July 10, and minus 10 days is May 22, so according to their interpretation, the next quarterly fire drill can be between May 22 to July 10.

But be aware: CMS does not like the idea that a quarterly fire drill could be conducted beyond the quarterly time period. Since the March 22 fire drill was conducted during the first quarter, they would want the second fire drill conducted during the second quarter, and July is not in the second quarter.