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NORTHERN COCHISE COMMUNITY HOSPITAL
CODE RED POLICY/PROCEDURE
DEPARTMENT: Safety
SUBJECT: Code Blue - Fire Response
Reviewed By:
| Review Date:
| Committee
| 07/20/17
| Med Staff
| 08/28/17
| Governing Board
| 09/26/17
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REFERENCES: CMS Guidelines and Life Safety Codes.
SCOPE: ALL NCCH STAFF.
PROCEDURE:
Introduction:
In the event of a fire emergency, the first responsibility of every employee is the safety of patients, visitors, and other staff members. It is necessary that each employee be aware of fire hazards and take steps to correct them. In the event of a fire, it is the responsibility of each employee to know and understand the fire procedure. Fire does not respect persons or places. A fire in a hospital can reach tragic proportions if the staff does not act immediately and correctly.
General Response:
A fire is considered to be any uncontrolled flame and/or smoke. When in doubt, respond as if a fire exists. "R.A.C.E." is the acronym used to represent the fire plan and describe the response to fire, smoke, or activation of the fire alarm. "R.A.C.E." is to be used in all areas and departments of the hospital.
R = Rescue people from smoke/fire.
A = Alarm pull fire alarm station, and call telephone extension: 6548 to announce "Code Red", the Area, and the Zone of the fire/smoke (For example: "Code Red - Area 1, Zone 4") repeat your "Code Red and location announcement three (3) times.
C = Contain the smoke/fire by closing all doors in the area.
E = Extinguish (when safe to do so) or Evacuate the fire area if the fire cannot be extinguished.
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Rescue:
Patients, visitors, and personnel in immediate danger of fire/smoke shall be moved to safety. The first responsibility is to rescue all parties from the fire/smoke.
Patients:
- In-patients in their rooms shall be evacuated to the hallway; and then through the nearest fire or smoke doors to protect the patient from the fire or smoke.
- Patients should be walked or carried to the hallway and then through the fire or smoke door. If a patient's condition requires them to be carried, use the appropriate carry for the situation.
- Wheelchair patients will be assisted to the hallway to ensure they have safely reached the hallway.
- Keep hallways clear of unnecessary equipment.
- Outpatients will be directed to exit through the nearest fire doors. Accompany the patients until they have safely exited through the fire doors.
Visitors:
Visitors will be directed to exit through the nearest fire doors. If they are visiting a patient they may stay with the patient during the evacuation. Do not allow a visitor to stay behind and fight the fire. Visitors will be treated as patients and will be moved to safety.
Personnel:
All personnel in the area shall assist in moving patients to safety immediately. As an employee, your first responsibility is to be sure all patients and visitors in immediate danger are moved to safety.
Law Enforcement Officers and Emergency Medical Personnel:
Law enforcement officers who have a patient in legal custody or have responsibility for the patient will remain with that patient and follow instructions given by hospital personnel. Their responsibility is to the person in custody. Emergency medical personnel in the facility at the time of the a fire alarm should report to the nearest staging area and wait for instructions from hospital personnel or the fire official.
Alarm:
The fire alarm sounds throughout the facility. The alarm system can be "set off" by pulling a fire alarm station - pull box. The hospital is equipped with an internal paging system which can be activated from any telephone.
Pull Boxes
- Fire alarm stations (pull boxes) are located in the hallways and by all fire exits of the facility. Exit signs mark the location of the fire exits.
- To operate a pull box, pull down on the handle breaking the glass rod.
- The facility is divided into zones allowing the staff to readily identify the location of an alarm. Alarm zone indicators are located in the following locations:
- Hospital Nurse's Station.
- Front door of Hospital (located in the air-lock separating doors).
- Entrance to Specialty Clinics.
- Each zone indicator station has a floor plan of the facility showing the alarm zones.
- Employees should be familiar with the location of the fire alarm stations "pull boxes" in their area and the alarm zone(s) where they work.
Paging (Telephone)
- The location of the fire/smoke can be paged throughout the hospital by following these steps:
- Utilize the phone system to make an overhead page.
- Announce "CODE RED".
- Give the Are and Zone location of the fire/smoke.
- Repeat the announcement of "CODE RED" and the location of the fire/smoke three (3) times.
Verbal Alarm
- Do not shout "FIRE" when you discover a fire or smoke.
- Alert nearby staff members by announcing to them "CODE RED" and the location of the fire/smoke.
Contain:
When Patients, visitors, and personnel have been moved to safety, and an alarm has sounded, begin containing the fire/smoke. Containing the fire/smoke will keep it from spreading to other parts of the immediate area.
Doors
- Check and close all doors surrounding the location of the fire or smoke.
- Check and close doors of adjoining rooms.
- Close fire and smoke doors and only open them to move patients through, or allow firefighters into the area.
- Before entering a closed door, feel the door in a "Z" pattern using the back of your hand. If it is hot, DO NOT OPEN THE DOOR.
Windows
- Check and close all windows in the area involved in the fire or smoke.
- DO NOT RISK YOUR SAFETY TO RETURN TO AN AREA TO SHUT A WINDOW.
Oxygen
- Turn off oxygen supply to the area involved in the fire/smoke.
- Oxygen valves are marked with green and white signs.
- Oxygen valves are located in the following areas:
- Laboratory Door - Controls oxygen outlets in OPSC.
- Hallway at room 112 - Controls oxygen outlets in 109, 110, 111, 112 & 114.
- Hallway at room 107 - Controls oxygen outlets in 104, 105, 107 & 108.
- Hallway across from room 104 - Controls oxygen outlets in CT room.
- Hallway at room 104 - Controls oxygen outlets in 101, 102 & 103.
- Inside the door of the Endoscopy area - Controls oxygen outlets in that immediate area.
- Inside door of Surgery (2 valves) - Controls oxygen outlets for Surgery and Recovery.
- Hallway at ED door - Controls oxygen outlets in ED, excluding outlets in north-end of ED.
- Hallway adjacent to the Lab Draw room off of hospital lobby - Controls oxygen outlets in that area.
Extinguish:
Fire extinguishers are provided, in accordance with NFPA 101 and State Code, in areas throughout the facility. In order to ensure that extinguishers function properly, they are regularly inspected and received regular preventative maintenance.
Fire Extinguishers
- Each employee should be familiar with the location of the fire extinguishers in their work area.
- When using a fire extinguisher, direct the flow at the base of the flames/fire.
- Stand far enough away from the fire so that you do not endanger your safety.
- Do not hamper the fire department with your attempts to extinguish the fire. Your first responsibility is to the safety of patients, visitors, and other staff members.
Responsibility of Staff:
When the alarm sounds, staff members in the immediate area need to assist in the evacuation of the patients, visitors, and all personnel to a safe area and place. Red tag the exterior handle of the rooms that have been cleared and are vacant.
Patient Care Areas:
The Charge Nurse will be responsible to ensure that all patients in immediate danger are moved to safety. As soon as possible following the alarm, and all patients in immediate danger having been moved, these steps will be carried out:
- One staff person in the patient care area shall be assigned the responsibility of calling "911" and verifying the situation.
- Advise the "911" Operator of the location of the fire/smoke and which hospital entry is closest to the area.
- Entrances to the hospital should be reported as follows:
- OPSC northeast entrance (Main Door).
- OPSC southeast entrance (Employee, vending machine entrance).
- Emergency Room Doors.
- Main entrance to hospital.
- Hall leading to Business Office (West side).
- During the day shift when an operator is on duty, that person should be notified of the "CODE RED", location of the fire, and nearest entrance for fire department to enter the building.
- Send one staff member to the entrance given to the "911" Operator and wait for the fire department to arrive. If staff is needed to move patients, do not send a staff person until patients have been safely moved.
- The responsibility of sending a staff person to wait for the fire department to arrive can be assigned to a staff person from another department.
Patient Records, Medications, and Supplies:
- The Charge Nurse will assign the responsibility of moving patients records to a safe location to one or more of the staff.
- The Charge Nurse will secure the medication cart and move it to a safe location.
- Specialized equipment such as code carts will be moved to a safe location.
Non-Patient Areas:
The same procedures used in patient care areas will be followed in other areas of the facility. The department manager or supervisor of the area will assign a staff member to make the follow-up call to "911". the location and nearest entrance needs to be provided. Each member of the staff should be familiar with the location of entrances into the building which can be used in the case of an emergency.
All Staff:
When the alarm is heard and the announcement made as to location of fire/smoke, staff not directly involved shall:
- Close all doors and windows in their work area and tag the door with a red tag to show that area has been cleared.
- Report to the staging area and wait for instructions.
- The following areas will server as staging areas for employees:
- OPSC Staff and Laboratory (if fire is not in the OPSC) - Report to OPSC reception - Staging Area 1 - Zones 4, 5, & 6.
- Hospital Nursing Staff, Dietary, Laundry, and Pharmacy (If fire is not in patient care area) - Report to hospital nursing station - Staging Area 2 - Zones 1, 2, & 3.
- Admitting, Gift Shop, Radiology, Respiratory Therapy, Emergency Room - Report to Front Lobby - Staging Area 3 - Zone 10.
- Housekeeping Staff - Report to the Staging Area of the Zone they are in, at the time of the alarm.
- Business Office, Purchasing, Health Information Management, Rehabilitation, Administration - Report to Business Offices - Staging Area 4 - Zone 9.
- Auxiliary Volunteers working floor - Report to Staging Area in their immediate area.
- All staff should be prepared to assist in the evacuation of patients, visitors, or other personnel.
- If additional staff assistance is required, the Administrator In Charge, Department Manager, or Charge Nurse will request additional staff from the Staging Areas.
- To request additional staff, call Staging Area and give location to send additional staff to.
- Five staff members from the Staging Area will be sent to assist. This will allow the Charge Person to control the number of staff in the fire zone.
Telephone Operators:
- The operation of the switchboard will be turned over to hospital employees when notified of a fire in the facility.
- Continue to answer all incoming calls, and ask non-emergency callers to return calls later so all lines in and out of the hospital are kept open for emergency communications.
- Provide the fire department with the information on location of fire.
- Be prepared to make necessary telephone pages as directed by the Administrator In Charge or fire department.
Maintenance Department:
- During day operations the Maintenance Department will serve as the hospital's fire brigade.
- The Maintenance Department Staff will report to the scene of the fire with fire extinguishers.
- If requested by the Charge Nurse the maintenance staff will help to rescue or evacuate patients.
- The maintenance staff will fight the fire until the arrival of the fire department.
- Shut off oxygen, suction, ventilation, and electrical equipment in the fire area as required.
- Perform other duties as directed by the fire department.
- Reset the alarm system after the fire emergency has ended.
- After normal work hours the on-call maintenance staff will be paged or telephoned immediately.
Administration:
- The CEO or Administrator In Charge will establish a fire center. The fire center will be located in a fire zone not affected by the fire.
- A disaster box will be secured and taken to the fire center.
- After hours the CEO or Administrator In Charge will be paged immediately.
- The CEO or Administrator In Charge and the fire department officials will make a decision to evacuate the facility.
- The CEO or Administrator In Charge will assign staff from the Staging Areas to help in evacuation and patient care.
Evacuation (Internal):
The decision to evacuate a fire area or the building will be given by the administrator, fire official, or Charge Nurse. Patients will be moved within the facility before evacuating them to an offsite location.
Patient Evacuation
- Patient will be moved to a different fire area than the one involved in the fire.
- Staff will be assigned necessary duties to ensure the safety of patients is maintained.
- Wheelchairs, stretchers, chairs and other patient transportation equipment will be moved with patients.
- If patients cannot be moved to a safe fire zone due to location of the fire, patients should be taken outside and then back into the facility at the safe entrance.
Patient Records, Medications and Supplies
- The Charge Nurse will assign the responsibility of moving patients' records to the evacuation area, to one or more of the staff.
- The Charge Nurse will secure the medication cart and move it to the evacuation area.
- Additional IV pumps will be moved to the evacuation area.
- Specialized equipment such as code carts will be moved to the evacuation area.
Non-Patient Areas
- The department manager or supervisor will direct employees to an adjoining safe fire zone.
Evacuation (External):
It is only under the most extreme circumstances that patients are ever to be moved from the building. The decision to evacuate the facility will be made by the fire department and Administrator In Charge. If it becomes necessary to evacuate, the following steps will be followed:
- Fire fighters and emergency medical personnel will be informed as to the condition of patients by the nursing personnel.
- The Charge Nurse will establish priority for the the removal of patients, and will designate personnel to be responsible for assisting in the evacuation.
- The Charge Nurse will check to make sure that all patients have been removed.
- The precise route and system of evacuation will be determined by the fire department.
- Patient records, medications, and supplies will be removed from the facility.
- Medical equipment required to care for patients will be removed from the facility after the safe evacuation of all patients.
- Hospital staff in Staging Areas will evacuate the facility under the direction of the fire department and Administrator In Charge.
Evaluation
Following each activation of the Fire Plan an evaluation may be conducted. The evaluation may be facilitated by CEO or the Chairman of the Safety Committee, and will include all staff directly involved with the fire, including local fire officials. Staff involved should record events directly following the fire so they may be reported during the evaluation.
The evaluation will be used to improve the Fire Plan and the response to a fire situation.
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SAFE-PLAN-010-1
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