Use of Fire and Smoke Doors During a Fire Drill


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.

Fire Drill Devices

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?


Woman dies during mock fire drill in Bangalore

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.


Fire Drills

Q: Do we have to conduct a fire drill in every department and unit at least once per shift per quarter throughout our hospital? Some staff is telling me that unless we do so, we are not meeting the Joint Commission requirement for fire drills. Is this true?

A: No, you do not. This is a frequently misunderstood aspect of the Joint Commission standard EC.02.03.03. The performance elements of this standard say fire drills must be conducted once per shift per quarter in each building (not each unit) that is defined as a healthcare occupancy. Where the misunderstanding comes in is the requirement for staff to participate in fire drills in buildings where patients are housed or treated, in accordance with the hospital’s fire response plan. At the source of the fire alarm staff has multiple requirements, but on units and floors away from the origin of the fire, there is little for staff to do other than close doors and be on alert. You may ‘spot-check’ your staff’s participation on units away from the origin of the alarm by having observers make note of the staff’s reaction. These observers may be individuals from your safety committee, or they may be managers of their respective departments.

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.