Emergency Management and Fire Safety

The International Board for Certification of Safety Managers developed the Certified Healthcare Emergency Professional (CHEP) credential in 2008� The Board believes that CHEP personnel can help to standardize management and system principles in the field of emergency planning, response, mitigation, and recovery� CHEP personnel, including nurses, working in healthcare facilities can lead the way by promoting healthcare emergency management as a “true” profession� Many of the CHEP credentialed individuals working in nonclinical and support areas understand the importance of coordinating healthcare emergency planning efforts� We can define an emergency as an unexpected or sudden event that significantly disrupts a healthcare organization’s ability to provide care or significantly changes or increases the demand for services� Emergencies can result from human-made or natural events or a combination of both� A disaster-type emergency, due to its complexity, scope, or duration, can threaten the organization’s capabilities� These events can require outside assistance to sustain patient care activities and facility safety or security� Healthcare organizations need to engage in planning activities to prepare a comprehensive Emergency Operations Plan (EOP)�

Healthcare facilities must prepare to respond to and recover from events using the all hazards planning approach� Hospitals must plan to maintain a medical surge capacity and capability that will support the community� Use a multidisciplinary process when conducting a healthcare facility risk assessment for emergency response planning� The healthcare hazard vulnerability analysis (HVA) must consider the impact of realistic emergency or disaster incidents� These incidents could include hazardous materials releases, industrial and chemical accidents, transportation accidents, natural disasters, and even bioterrorism events� The HVA process must also assess the probability of each type of event, risks involved, and the organization’s level of preparedness to respond� Emergency management consists of mitigation, preparedness, response, and recovery phases� These four phases occur over time, with mitigation and preparedness generally occurring before an emergency� Response and recovery phases usually occur during or after an emergency event�

The EOP identifies the individuals with the authority to activate the response and recovery phases of the emergency response� The plan must identify alternative sites for care, treatment, and services that meet the needs of the hospital patients during emergencies� The Joint Commission spells out emergency management-related responsibilities in its Emergency Management Standard�

The Joint Commission Standard provides excellent guidance for accomplishing actions to support the four phases of emergency management� The Joint Commission allows hospitals to develop a single HVA that accurately reflects all sites of the hospital, or the organization can develop multiple HVAs� Some remote sites may be significantly different from the main hospital site� Community partners may include other healthcare organizations, public health departments, vendors, community organizations, public safety and public works officials, representatives of local municipalities, and other government agencies� The hospital must communicate its needs and vulnerabilities to

community emergency response agencies and identify the community’s capability to meet its needs� This communication and identification should occur at the time of the hospital’s annual review of the EOP and whenever its needs or vulnerabilities change� The hospital hazard vulnerability analysis provides the basis for defining mitigation activities needed to reduce the risk of damage during an emergency� Hospital leaders, including members of the medical staff, should participate in planning activities prior to developing an EOP� Ensure the plan addresses mass casualty situations, including terrorist events of a chemical, biological, or radiological nature� The plan should consider risks and their potential liabilities� Coordinate plans for maintaining a predictable environment of care during any emergency situation� Develop plans to guide response for any situation� The plan must provide for a command structure to assess situations, coordinate actions, and make decisions� Plan to deal with any situation that significantly disrupts the environment of care or patient treatment�

Planners should reference National Fire Protection Association (NFPA) 1600, NFPA 99, 29 CFR 1910�138, 40 CFR 264, applicable accreditation standards, and Department of Homeland Security (DHS) publications for additional information and guidance� Provide realistic training and education for all emergency personnel� Ensure all staff members understand their roles and responsibilities� Validate their understanding during readiness drills� Educational sessions can help reduce fear or anxiety among hospital personnel responding to terrorism-type events� Train medical and hospital staff to report unexpected illness patterns to appropriate agencies� When possible, ensure a physician meets with the local media to provide updated information about medical issues� Make the public aware of any changes in hospital treatment procedures� Ensure the incident command integrates into the community’s command structure� The incident command structure should provide scalable mechanisms to better respond to different types of emergencies� The hospital should maintain an inventory of the resources and assets� These assets should include but never be limited to personal protective equipment, water, fuel, and medical-, surgical-, and medication-related resources and assets�

The local EOP must guide the coordination of communications, resources, assets, safety and security, and staff responsibilities� The plan must address patient, clinical, and support activities during an emergency� Emergencies may vary but the effects on these organization functions may be similar� This “all hazards” approach supports a general response capability sufficiently nimble to address a range of emergencies of different duration, scale, and cause� The EOP permits response procedures to address prioritized emergencies� A comprehensive but flexible EOP can guide decision-making at the onset and as a situation evolves� Response procedures should address the following: (1) maintaining or expanding services, (2) conserving resources, (3) curtailing services, (4) supplementing resources from outside the local community, (5) closing the hospital to new patients, and (6) staged evacuation or total evacuation� The EOP describes the processes for initiating and terminating the hospital’s response and recovery phases of an emergency, including under what circumstances these phases are activated� It also identifies the hospital’s capabilities and establishes response procedures for when the hospital can’t be supported by the local community� Hospitals should plan to stockpile enough supplies to last for 96 hours of operation� The EOP should describe the recovery strategies and actions designed to help restore the systems that are critical to providing care, treatment, and services after an emergency�

Develop contingency plans to ensure the availability of critical supplies� Examples of resources and assets that might be shared include beds, transportation, linens, fuel, personal protective equipment, medical equipment, and supplies� The EOP describes the hospital’s arrangements for transporting some or all patients, their medications, supplies, equipment, and staff to an alternative care site when environments can’t support care, treatment, and services� The EOP also addresses the arrangements for transferring pertinent information, including essential clinical and medicationrelated information, with patients moving to alternative care sites� The EOP should describe the hospital’s arrangements for internal security and safety� It should also address the roles that community security agencies will play in supporting security activities� The EOP must also describe how the hospital will manage hazardous materials and wastes� Plan to address radioactive, biological,

and chemical isolation or decontamination activities� The Joint Commission requires hospitals to provide safe and effective patient care during an emergency� Document staff roles and responsibilities in the EOP� Due to the dynamic nature of emergencies, effective training prepares staff to adjust to changes in patient volume or acuity� The EOP should describe the process for assigning staff to all essential staff functions�

The hospital must communicate, in writing, with each of its licensed independent practitioners regarding his or her role in emergency response and to whom they report� The Joint Commission provides guidance to its accredited facilities on how to grant disaster privileges to volunteer licensed independent practitioners when the EOP has been activated� The medical staff must describe how it will oversee the performance of volunteer licensed independent practitioners granted disaster privileges� Before determining whether a volunteer practitioner is eligible to function as a volunteer licensed independent practitioner, the hospital should obtain his or her valid government-issued photo identification and at least one of the following: (1) current picture identification card from a healthcare organization that clearly identifies professional designation, (2) current license to practice, (3) primary source verification of licensure, (4) identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), the Medical Reserve Corps (MRC), the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), or other recognized state or federal response organization or group, (5) identification indicating that the individual possesses granted authority by a government entity to provide patient care, treatment, or services in disaster circumstances, or (6) confirmation by a licensed independent practitioner privileged by the hospital or by a staff member with personal knowledge of the volunteer practitioner’s ability to act as a licensed independent practitioner during a disaster� During a disaster, the Joint Commission requires that medical staff oversee the performance of each volunteer licensed independent practitioner� Primary source verification of licensure occurs as soon as a disaster is under control or within 72 hours from the time the volunteer licensed independent practitioner presents him or herself to the hospital, whichever comes first� If primary source verification of a volunteer licensed independent practitioner’s licensure cannot be completed within 72 hours of the practitioner’s arrival due to extraordinary circumstances, the hospital documents all of the following: (1) reasons it could not be performed within 72 hours of the practitioner’s arrival, (2) evidence of the licensed independent practitioner’s demonstrated ability to continue to provide adequate care, treatment, and services, or (3) evidence of the hospital’s attempt to perform primary source verification as soon as possible�

The Joint Commission requires hospitals to conduct an annual review of its planning activities to identify such changes and support decision-making regarding how the hospital responds to emergencies� The hospital must also conduct an annual review of its risks, hazards, and potential emergencies as defined in its HVA� The hospital must conduct an annual review of the objectives and scope of its EOP� The findings must be documented�

Facilities must conduct exercises to assess EOP appropriateness, adequacy, and effectiveness� Key areas to evaluate include logistics, human resources, training, policies, procedures, and protocols� Exercises should stress the limits of the plan to support assessment of preparedness and performance�

The design of the exercise should reflect likely disasters but should test the organization’s ability to respond to the effects of emergencies on its capabilities to provide care, treatment, and services� For each site of the hospital that offers emergency services or a community-designated disaster receiving station, at least one of the two required emergency response exercises or drills must include an escalating event in which the local community is unable to support the hospital� Tabletop sessions are acceptable in meeting the community portion of this exercise� For each site of the hospital with a defined role in its community’s response plan, at least one of the two emergency response exercises must include participation in a community-wide exercise� Tabletop sessions meet only community portions of the exercise� Emergency response exercises incorporate likely disaster scenarios that allow the hospital to evaluate its handling of communications, resources and assets,

security, staff, utilities, and patients� Staff in freestanding buildings classified as business occupancies that do not offer emergency services nor are designated by the community as disaster-receiving stations need to conduct only one emergency management exercise annually� Tabletop sessions, though useful, are not acceptable substitutes for these exercises�

The hospital should designate individuals to monitor drill or exercise performance and document opportunities for improvement� This person must be knowledgeable in the goals and expectations of the exercise and may be a staff member� Hospitals may use observations of those involved in the command structure as well as the input of those providing services during an actual emergency� The hospital must evaluate all emergency response exercises and all responses to actual events using a multidisciplinary process� Communicate all identified deficiencies and opportunities for improvement to the improvement team responsible for monitoring environment of care issues� The hospital must modify the EOP based on findings of emergency exercises and actual events�

The facility must maintain a written inventory of utility system components considering risks for infection, occupant needs, and systems critical to patient care� The facility must identify in writing inspection and maintenance activities for operating components, and must identify the intervals for inspecting, testing, and maintaining all operating utility systems using manufacturer recommendations, risk levels, or hospital experience� The facility must also take actions to minimize pathogenic biological agents in cooling towers, domestic hot and cold water systems, and other aerosolizing water systems�

It must map and document distribution of its utility systems, label utility system controls to facilitate partial or complete emergency shutdowns, and develop written procedures for responding to utility system disruptions�

In order to maintain daily operations and patient care services, healthcare facilities need to develop an Emergency Water Supply Plan (EWSP) to prepare for, respond to, and recover from a total or partial interruption of the facilities’ normal water supply� Water supply interruption can be caused by several types of events such as a natural disaster, a failure of the community water system, construction damage, or even an act of terrorism� Because water supplies can fail, it is imperative to understand and address how patient safety, quality of care, and the operations of your facility will be impacted� Below are a few examples of critical water usage in a healthcare facility that could be impacted by a water outage� Water may not be available for hygiene, drinking, food preparation, laundry, central services, dialysis, hydrotherapy, radiology, fire suppression, water-cooled medical gas, suction compressors, HVAC operation, decontamination, and hazmat response� A healthcare facility must be able to respond to and recover from a water supply interruption� A robust EWSP can provide a road map for response and recovery by providing the guidance to assess water usage, response capabilities, and water alternatives� The EWSP will vary from facility to facility based on site-specific conditions and facility size� Regardless of size, a healthcare facility must develop an effective EWSP to ensure patient safety and quality of care while responding to and recovering from a water emergency�

Healthcare facilities are a critical component to a community’s response and recovery following an emergency event� A number of incidents could impact the water supply of a healthcare facility� In the case of some natural disasters, such as a hurricane or flood, a facility may know days ahead of the risks� These events allow more time for preparation, which typically speeds up response� Earthquakes, tornados, or external/internal water contamination can occur with little or no warning� Joint Commission standards address the provision of water as part of the facility’s EOP� Centers for Medicare & Medicaid Services (CMS) conditions for participation/coverage also require healthcare facilities to make provisions in their preparedness plans for situations in which utility outages of gas, electric, or water may occur� Incorporate the principles and concepts of the plan into the overall facility EOP� It remains vital that the EWSP receives an annual review� Exercise and revise the plan on a regular basis or at least annually� The process of developing an EWSP for a healthcare facility will depend on the size of the facility and will require the participation and collaboration of both internal and external stakeholders�

For a small facility (less than 50 beds) where one individual performs multiple functions, the process may be relatively simple, with a single individual coordinating development of the EWSP� However, for a large hospital of several hundred beds, the process of developing the plan will be more complex�

Develop plans for evacuating the facility either horizontally and/or vertically� Also plan to identify care providers and other personnel during emergencies� Create a priority listing of institutions or facilities to which the patients or residents will be evacuated� Specify the locations that will serve as a staging area pending further decisions� Develop procedures for obtaining an accurate account of personnel after a completion of the evacuation� Designate assembly areas where personnel should gather after evacuating� Establish a method for accounting for nonemployees such as suppliers and visitors� Establish procedures for further evacuation in case the incident expands� The Americans with Disabilities Act (ADA) defines a disabled person as anyone with a physical or mental impairment that substantially limits one or more major life activities� Emergency planning priorities must consider disabled visitors and employees�

FEMA developed a publication titled A Guide to Citizen Preparedness (FEMA Publication H-34). The guide contains facts on disaster survival techniques, disaster-specific information, and how to prepare for and respond to both natural and man-made disasters� Healthcare organizations must adopt a community-wide perspective when planning for mass casualty incidents� Senior leaders must maintain a good relationship with response agencies in the community, including other area healthcare facilities� Clinics and nursing homes may play key roles in large disasters� Public health departments will usually institute appropriate public health interventions, including immunizations and prophylactic antibiotics� Establish working relationships with all responders including local emergency management agencies, law enforcement personnel, and local fire officials� Coordinate the healthcare emergency plan with the official responsible for area wide disaster planning�

The Partnership for Community Safety: Strengthening America’s Readiness serves as a new coalition formed to advocate for strengthening community readiness for biological, chemical, or nuclear terrorism and other disasters� The Partnership will call on federal policymakers to support and sustain comprehensive readiness efforts in the nation’s public health departments, emergency departments, hospitals, fire services, ambulance and emergency medical services (EMS) organizations, medical education institutions, and the nursing profession� While proposals pending in Congress represent important first steps, the Partnership will advocate for a comprehensive and sustained approach to community readiness� Partnership members believe the tragic events of September 11 and the subsequent anthrax incidents demonstrate the urgency for strengthening community preparedness plans to protect the public from acts of terrorism� In addition to working together to help shape national policy, the new alliance will promote collaboration among its members to retool disaster plans and focus on the need to increase capacity for frontline responders to prepare for the new challenges of terrorism� In addition, Partnership members will work to reduce duplication of effort and develop a “bank” of best practices through exchanging ideas and highlighting model plans� The Partnership also plans to educate the public about local readiness issues� The Partnership for Community Safety: Strengthening America’s Readiness represents firefighters, paramedics and other EMS professionals, emergency physicians, all other physicians, hospital officials, medical education professionals, public health officials, nurses, and state regulatory agencies in the United States�

Healthcare organizations must work to help assess community health needs and available resources to treat evacuees from other areas� The organization must determine community priorities as identified in the hazard vulnerability analysis� Clarify the organization’s role during the annual community-wide emergency exercise� Develop plans for coordinating with the media� Establish a media briefing area with established security procedures� Establish procedures for ensuring the accuracy and completeness of all information approved for public release� Provide for decontamination and treatment for any and all victims� Promote a wider level of preparedness in the community by providing low-cost hazard communication or hazardous waste operations and emergency response (HAZWOPER) training for local government and business emergency response personnel� Provide information and services related to emergency preparedness� Participate actively in community planning and preparedness activities�

Healthcare facilities should focus on the following key areas when conducting planning:

• Communication: Assess the ability of the organization to maintain communications within the organization and with all appropriate community disaster resource agencies�

• Resources and Assets: Develop plans to access necessary materials, supplies, vendors, community resources, and government support if necessary to sustain operations such as patient care, safety, and medical services�

• Safety and Security: Create contingency plans to ensure the safety and welfare of all patients, staff, and visitors during emergencies and disasters�

• Staff Responsibilities: Design appropriate curriculums to orient, educate, or train staff members about their changing roles and demands during emergency incidents�

• Utilities Management: Establish plans for maintaining key utilities such as drinking water, power sources, ventilation, and fuel supplies�

• Clinical Support Activities: Establish clinically coordinated policies and procedures that ensure patient care during extreme emergency conditions when organizational resources are stretched�

There are five basic functional areas of management during a major incident including (1) command, (2) operations, (3) planning, (4) logistics, and (5) finance/administration� An Incident Command System (ICS) coordinates responses involving multiple jurisdictions or agencies� It retains the principle of unified command for coordinating the efforts of many jurisdictions� The system must ensure joint decisions in areas such as objectives, strategies, plans, priorities, and communications� The system focuses on responder readiness to manage and conduct incident actions by coordinating before an event� Some benefits include (1) maintaining a predictable chain of accountability, (2) flexible response to specific incidents, (3) improved documentation, (4) common language to facilitate outside assistance, (5) prioritized response checklists, and (6) cost-effective planning�

BOX 5.1 COMMON ICS PRINCIPLES

• Common Terminology: The use of similar terms and definitions for resource descriptions, organizational functions, and incident facilities across disciplines�

• Integrated Communications: The ability to send and receive information within an organization and externally to other disciplines�

• Modular Organization: Assets within each functional unit may be expanded or contracted based on the requirements of the event�

Assign the duties to certain positions and never to specific individuals� The incident commander must maintain emergency command center effectiveness, ensure communications, and maintain security� Key duties include providing public information and media releases, coordinating facilities, sheltering, feeding, and counseling as needed� The incident commander must oversee establishing the morgue and making EMS available as needed�

The Centers for Disease Control and Prevention’s (CDC’s) Strategic National Stockpile (SNS) maintains large quantities of medicine and medical supplies to protect the American public if there is a public health emergency such as a terrorist attack, flu outbreak, or earthquake severe enough to cause local supplies to become diminished� Once federal and local authorities agree on the need for SNS, medicines will be delivered to any state in the United States in time for them to be effective� Each state has a plan to receive and distribute SNS medicine and medical supplies to local communities as quickly as possible� The SNS contains enough medicine to protect people in several large cities at the same time� Federal, state, and local community planners work together to ensure that the SNS medicines will be delivered to the affected areas if there is a terrorist attack� Local communities are prepared to receive SNS medicine and medical supplies from the state to provide them to everyone in the community who needs them� The SNS consists of a national repository of antibiotics, chemical antidotes, antitoxins, life-support medications, IV administration, airway maintenance supplies, and medical/surgical items� SNS can supplement and resupply state and local public health agencies in the event of a national emergency anywhere and at anytime within the United States or its territories�

If the incident requires additional pharmaceuticals and/or medical supplies, vendor managed inventory (VMI) supplies will be shipped to arrive within 24 to 36 hours� If well defined, the agent VMI can be tailored to provide pharmaceuticals, supplies, and/or products specific to the suspected or confirmed agent(s)� In this case, the VMI could act as the first option for immediate response from the SNS Program� The first line of support lies within the immediate response 12-hour Push Packages� These are caches of pharmaceuticals, antidotes, and medical supplies designed to provide rapid delivery of a broad spectrum of assets for an ill-defined threat in the early hours of an event� These Push Packages are positioned in strategically located, secure warehouses ready for immediate deployment to a designated site within 12 hours of the federal decision to deploy SNS assets� However, SNS does not function as a first-response tool�

BOX 5.2 COMMON ICS PRINCIPLES

• Unified Command Structure: Disciplines and response organizations work through designated managers to establish common objectives and strategies to reduce conflict or duplication�

• Span of Control: The structure permits each supervisory level to oversee an appropriate number of assets based on size and complexity of the event�

• Span of Control Ratio: Maintaining effective supervision with an element supervising three to seven entities, with five being the ideal�

• Consolidated Incident Action Plans: Goals, objectives, strategies, and major assignments are defined by the incident commander or by unified command�

• Comprehensive Resource Management: System processes are in place to describe, maintain, identify, request, and track all resources within the system during an incident�

• Pre-Designated Incident Facilities: Assign locations where expected critical incidentrelated functions will occur and ensure adequate space and technical support for the assigned function�

Hospitals make up a substantial portion of the emergency response system� Educate and train staff about possible events and appropriate response actions� Potential risks associated with nuclear, chemical, biological, or radiological weapon attacks by terrorists call for sound emergency planning procedures� Terrorist events can result in potentially large numbers of casualties� The psychological impact of weapons of mass destruction and the relative ease of their acquisition poses a great threat� Healthcare facilities preparing for a bioterrorism response plan should reference A Template for Healthcare Facilities, produced by the Association for Professionals in Infection Control� This resource outlines the steps necessary for responding to biological agents, such as smallpox, botulism toxin, anthrax, and plague, and provides information on the unique characteristics, specific recommendations, management, and follow-up for each of these agents� The CDC National Public Health Strategy for Terrorism Preparedness & Response Guide contains information on the following topics: (1) detection, investigation, and laboratory sciences; (2) prevention efforts, worker safety, and communication; (3) emergency response; (4) research and long-term consequence management; and (5) workforce development�

The Department of Health and Humans Services (DHHS) Supplement 3 provides healthcare partners with recommendations for developing plans to respond to a pandemic� Focus on planning during the Interpandemic Period for issues such as surveillance, decision-making structures, communications, education and training, patient triage, clinical evaluations, admission, facility access, occupational health, distribution of vaccines, antiviral drugs, surge capacity, and mortuary issues� The activities suggested in Supplement 3 are intended to be synergistic with those of other pandemic influenza planning efforts, including state preparedness plans� Healthcare facilities must be prepared for the rapid pace and dynamic characteristics of pandemic influenza� All hospitals should be equipped and ready to care for a limited number of patients infected with a pandemic influenza virus, or other novel strains of influenza� Hospitals should prepare for a large number of patients in the event of escalating transmission of pandemic influenza� Healthcare facilities must develop planning and decision-making structures for responding to pandemic� This planning includes developing written plans that address (1) disease surveillance, (2) hospital communications, (3) education and training, (4) triage and clinical evaluation, (5) facility access, (6) employee health, (7) use and administration of vaccines or antiviral drugs, (8) surge capacities, (9) supply chain issues, (10) access to critical inventory needs, and (11) mortuary related issues�

Facilities contain many fire-related hazards including medical equipment, combustible gases, chemicals with low flash points, and electrical hazards of all types� Planning should consider proper design, including prevention features and egress safety� Fire response planning remains a key element of any emergency management process�

Fire begins with no visible smoke, flames, or significant heat� However, a large number of combustion particles generate over time� The particles created by chemical decomposition possess both weight and mass but remain too small for the eye to see� They behave according to gas laws and quickly rise to the ceiling� As this incipient stage continues, the combustion particles increase until they become visible and create a condition called “smoke�” As the fire continues to develop, ignition occurs and flames begin� The level of visible smoke decreases and heat levels increase� At this point the process produces large amounts of heat, flame, smoke, and toxic gases�

The life safety concept began in 1963 with the publication of the Building Exits Code� The NFPA published its First Edition of the Life Safety Code® in 1966� Building codes provide design criteria

but NFPA 101® addresses the general requirements for fire protection and systems safety necessary to assure the safety of building occupants during a fire� The code provides minimum requirements for the design, operation, and maintenance of healthcare organization buildings and structures� NFPA 101 requires that new and existing buildings allow for prompt escape or provide occupants with a reasonable degree of safety through other means� It defines hazards and addresses general requirements for egress and covers fire protection features such as fire doors� The code also addresses building service and fire equipment such as heating, ventilating, air conditioning systems, sprinkler systems, fire detection systems, and localized extinguishers� New editions of the code build on the prior editions�

The 2012 edition of the Life Safety Code offers new design and compliance options for healthcare facilities� Since all jurisdictions do not use the same edition of the code, CMS and the Joint Commission permit the use of the 2012 edition in its entirety or on a single-element basis� The American Society for Healthcare Engineering (ASHE) developed a monograph in 2013 that provided summary changes in the new code� The monograph also provided a comparison of the 2012 Code with the 2000 and 2009 editions� The monograph presented three different options for upgrading from the 2000 edition to the 2009 or 2012 edition� The monograph provided guidance about waivers and equivalencies for using the newer editions of the code�

BOX 5.3 BASIC FIRE PLAN REQUIREMENTS

• Policies implemented to manage fire safety • Processes developed to protect humans from fire and smoke • Procedures for inspecting, testing, and maintaining fire protection systems • Facility-wide fire response procedures • Area-specific needs including fire evacuation routes • Specific roles and responsibilities of staff at the fire’s point of origin • Specific roles and responsibilities of staff in preparing for building evacuation

BOX 5.4 OSHA FIRE PLAN ELEMENTS (29 CFR 1910.38)

• Fire department notification and follow-up procedures • Procedures for announcing the fire location using an appropriate method • Locations for key personnel to assemble and manage the decisions • Designated personnel who will meet and direct fire department personnel • Procedure for holding nonemergency calls and giving an “all-clear” signal

BOX 5.5 TOPICS TO CONSIDER WHEN DEVELOPING FIRE RESPONSE PLANNING

• Specific needs related to fire evacuation and egress routes • Specific roles and responsibilities for all staff • Specific roles and responsibilities for patient evacuation • Information about alarm systems and signals • Information related to the location and use of firefighting equipment • Information related to fire containment procedures

Design, construct, maintain, and operate a building to minimize the possibility of a fire requiring the evacuation of occupants� Develop procedures to address

• Design, construction, and compartmentalization • Provision for detection, alarm, and extinguishments systems • Fire prevention planning and training • Isolation of fire • Evacuation of the building or the transfer of occupants to areas of refuge

Buildings must contain a fire alarm or fire detection system that should automatically activate an alarm in the event of a fire� Install air conditioning, ducts, and any related equipment in accordance with NFPA 90A, Standard for Installation of Air Conditioning and Ventilating Systems� Ensure people can hear fire alarms over normal operational noise levels� Locate manual fire alarm stations near each exit� Inspect fire extinguishers at least monthly and ensure regular maintenance� Test fire alarm/detection systems once a quarter� Publish and enforce a Smoking Policy� Implement appropriate electrical safety policies and educate all personnel about fire safety and response plans�

Conduct quarterly fire inspections for each fire zone� Accomplish the following:

• Assess all equipment including the testing of alarms, detectors, and pull stations • Evaluate housekeeping practices and sprinkler pressure inspection procedures • Check water availability and fire hydrant operation • Check suppression, detection, and activation systems annually • Coordinate inspections with the local fire marshal and facility engineering

Ensure all systems meet NFPA standards and local requirements� All manually operated fire systems must be electrically supervised� The system must also automatically transmit an alarm to the fire department� Notify the local fire department by other means when the alarm has been activated�

BOX 5.6 GENERAL FIRE DRILL PROCEDURES

• Provide information on location of fire, type of fire, and equipment failures • Ensure installation of an effective and convenient fire alarm system • Shut off oxygen and gas valves if possible and disconnect unnecessary equipment • Reassure patients and visitors about the implementation of emergency plans • Ensure a realistic implementation of the fire plan and conduct drills at varied times • Critique drills to identify deficiencies and opportunities for improvement

BOX 5.7 FIRE ALARM TYPES

• Central Station Service (NFPA 71) • Auxiliary Protective Signaling Systems (NFPA 72) • Proprietary Protective Signaling System (NFPA 72) • Remote Station Protective Signaling System (NFPA 72)

2. Manual Alarm Stations Locate manual alarm stations throughout the facility� Position the alarms to ensure travel distances of no more than 200 feet when located on the same floor� Design audible alarms to exceed the level of any operational noise� Use audible alarms with visual alarms�

3. Electrically Supervised Systems Monitor all components to ensure personnel are aware of when the system needs repair� The system should signal trouble when

• A break or ground fault prohibits normal system operation • The main power source fails • A break occurs in the circuit wiring

4. Special Requirements for Cooking Areas Install approved systems to protect cooking surfaces, exhaust hoods, and ducts� Consider the following types of systems:

• Automatic carbon dioxide systems • Automatic dry chemical systems • Automatic foam water or wet chemical systems • Automatic sprinkler systems approved by NFPA 13

5. Fire System Inspections All systems should receive a visual inspection each quarter� Test or inspect each automatic system on an annual basis� Include all systems in the preventive maintenance plan� Test all supervisory signal devices except valve tamper switches on a quarterly basis� Test valve tamper switches and water flow devices semiannually� Test duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors on a semiannual basis� Test occupant alarm notification devices to include audible and visible devices at least annually� Maintain appropriate documentation on all fire-related system testing�

Confinement measures consist of dividing a building into small cells� To assure proper protection of openings, install fire doors in accord with NFPA 80, Standard for Fire Doors and Fire Windows� Evaluate the movement of smoke within a structure by considering many factors such as building and ceiling height, suspended ceilings, ventilation, and external wind force or direction� One method of smoke control uses a physical barrier, such as a door or damper, to block the smoke’s movement� Regardless of the type of building construction, stair enclosures must provide a safe exit path for occupants� Stair enclosures also retard the upward spread of fire�

BOX 5.8 GENERAL REQUIREMENTS FOR ALARMS

• Fire alarms must be received at a central location within the facility� • Continuously man and supervise all locations� • Protect supervised locations as a hazardous area� • Signals received must transmit at once to the local fire department� • Provide a copy of the master fire plan at all supervised locations�

Designing exits involves more than a study of numbers, flow rates, and population densities� Exits must provide alternative pathways to counter potential exit blockage by fire� Each employee should recognize and report fire safety hazards�

Exit doors must withstand fire and smoke for a specified length of time� Provide alternative exits and pathways in case fire blocks an exit� Provide exits with adequate lighting and mark exits with readily visible signs� Develop plans to evacuate disabled or wheelchair employees to meet Occupational Health and Safety Administration (OSHA) requirements� The ADA Title III requires organizations to develop plans to safely evacuate disabled visitors�

1. OSHA Egress Standards OSHA defines a means of egress as a continuous and unobstructed way of exit that travels from any point in a building or structure to a public way and consists of three parts:

• Exit access: That portion that leads to the entrance of an exit� • Exit: That portion separated from all other spaces of a building or structure by construc-

tion or equipment to provide a protected way of travel to the exit discharge� • Exit discharge: That portion between the termination of an exit and a public way

This subsection covers the basic type of equipment used to fight and control fires� The first type of equipment, known as a fixed system, includes automatic sprinklers, standpipe hoses, and various pipe systems� Supplement fixed systems by providing appropriate types and sizes of portable extinguishers� Train personnel expected to use portable fire extinguishers on their operation and safe use�

1. How Fire Extinguishers Work Portable fire extinguishers apply an existing agent that will cool burning fuel, displace or remove oxygen, or stop the chemical reaction so a fire cannot continue to burn� When the handle of an extinguisher is compressed, it opens an inner canister of high-pressure gas that forces the extinguishing agent from the main cylinder through a siphon tube and out the nozzle� Fire creates a very rapid chemical reaction between oxygen and a combustible material, which results in the release of heat, light, flame, and smoke�

BOX 5.9 BASIC “PASS” GUIDELINES FOR EXTINGUISHER USE

• Pull the pin on the extinguisher • Aim the nozzle at the base of the fire • Squeeze the handle firmly • Spray in a sweeping motion

BOX 5.10 EXTINGUISHER CLASSES

• Class A: For fires involving ordinary combustible materials, such as wood, paper, or clothing, where the quenching and cooling effects of water prove most effective, use a pressurized water extinguisher or ABC type dry powder extinguisher�

• Class B: For fires involving flammable liquids and similar materials, use type BC or ABC dry powder extinguishers� Carbon dioxide (CO2) extinguishers may also be used�

(Continued)

2. Proper Maintenance Proper maintenance includes a complete examination, and involves disassembly and inspection of each part and replacement where necessary� Conduct maintenance at least annually or more often if conditions warrant� Perform hydrostatic testing of portable fire extinguishers to protect against unexpected in-service failure� Failure can occur due to internal corrosion, external corrosion, and damage from abuse� Perform hydrostatic testing using trained personnel with proper equipment and facilities� OSHA Standard, 29 CFR 1910�157, Table 1 provides test intervals for extinguishers�

Fires occurring on or inside a patient rarely occur but can cause grave consequences� They can kill or seriously injure patients, injure surgical staff, and damage critical equipment� Flammable materials present in surgical suites range from alcohol-based prepping agents to drapes, towels, gowns, hoods, and masks� Common ignition sources found in operating rooms include electrosurgical or electrocautery units, fiber-optic light sources and cables, and lasers� High-speed drills can produce incandescent sparks that can fly off the target tissue and ignite some fuels, especially in oxygenenriched atmospheres� Staff should participate in special drills and training on the use of firefighting equipment� They should know the proper methods for rescue and escape�

BOX 5.10 EXTINGUISHER CLASSES (Continued)

• Class C: For fires in or near energized electrical equipment where the use of a nonconductive extinguishing agent is of first importance, use CO2, or dry powder (BC or ABC)� NEVER USE WATER�

• Class D: Metal fires-combustible metals such as magnesium and sodium require special extinguishers labeled D�

• Class K: Grease fires-use a portable extinguisher designed especially for cooling these types of fire�

BOX 5.11 FIRE EXTINGUISHER PLACEMENT & TRAVEL DISTANCES

• Class A: Travel distance of 75 feet or less • Class B: Travel distance of 50 feet or less • Class C: Travel distance based on appropriate A or B hazard • Class D: Travel distance of 75 feet

BOX 5.12 MONTHLY EXTINGUISHER INSPECTIONS

• Determine proper location and type • Ensure accessibility to all extinguisher locations • Document the proper mounting of each extinguisher • Check gauges to determine adequate pressure • Verify proper placement of pins and seals • Look for evidence of damage or tampering • Ensure no blockage of nozzles

Ensure each staff member knows the identification and location of medical gas, ventilation, and electrical systems including controls� Educate staff on how to use the hospital’s alarm system and contact the local fire department� Healthcare organizations can prevent fires by

• Informing staff members, including surgeons and anesthesiologists, about the importance of controlling heat sources by following published safety practices�

• Managing fuels by allowing sufficient time for patient prep and establishing guidelines for minimizing oxygen concentration under the drapes�

• Developing, implementing, and testing procedures to ensure appropriate response of all members of the surgical team�

• Reporting any instances of surgical fires as a means of raising awareness and ultimately preventing the occurrence of fires in the future�

1. ASTM Surgical Fire Standard Refer to the ASTM Standard Guide to Surgical Fires: Fire Risk Assessment, Prevention, and Extinguishment� The Guide was developed by ASTM Committee F29 on Anesthetic and Respiratory Equipment� The standard offers instruction on the risks of potentially flammable materials used in surgery and provides some much-needed guidance for doctors, nurses, anesthesiologists, technicians, engineers, risk managers, and health administrators�

BOX 5.13 PREVENTING SURGICAL FIRES

• Minimize ignition risks during use of electrosurgical devices and surgical lasers including the safe and appropriate use of electrosurgical pencils and the use of bipolar electro surgery devices�

• Lessen ignition risks by selective wetting of fuels present at the incision, including gauze, sponges, and towels�

• Implement all general procedures established to minimize ignition risks� • Specific procedures to minimize ignition risks in oropharyngeal surgery include gas scav-

enging and using wet gauze, sponges, or pledgets� • Minimize the oxidizer risks of oxygen and nitrous oxide used in general surgery and spe-

cifically during oropharyngeal surgery� • Reduce fuel risks when using flammable surgical instruments� • Educate personnel on fire prevention and conduct drills for the operating room setting�

BOX 5.14 RESPONDING TO SURGICAL FIRES

• Extinguish small fires by hand� • Response to large fires on or in the patient: stop the flow of oxidizers, remove burning

materials from the patient, extinguish burning material, and care for the patient� • Follow correct procedures for using the recommended type of fire extinguisher, such as

carbon dioxide� • Do not use water-based and dry-powder extinguishers� • Rescue the patient, alert the staff, confine the smoke or fire, and evacuate the area� • Recommend mounting a five-pound CO2 extinguisher just inside the entrance of each oper-

ating room�

2. Fire Blankets Never locate wool blankets treated with fire retardants in the operating room and never use them for patient fires� Their use will likely cause more severe injuries to the patient� However, they could help when responding to use on a conscious person, such as a surgical team member�

Healthcare facilities must design and manage the physical environment to comply with the Life Safety Code� Assign an individual(s) to assess compliance with the Life Safety Code� The facility must complete the electronic Statement of Conditions and manage the resolution of deficiencies� The hospital must maintain a current electronic Statement of Conditions� When the hospital plans to resolve a deficiency through a Plan for Improvement (PFI), the hospital must meet the time frames identified in the PFI accepted by the Joint Commission� Hospitals accredited by the Joint Commission must maintain documentation of any inspections and approvals made by state or local fire control agencies� The hospital must protect occupants during periods when the Life Safety Code is not met or during periods of construction� The hospital must notify the fire department or other emergency response group and initiate a fire watch when a fire alarm or sprinkler system is out of service more than 4 hours in a 24-hour period in an occupied building�

Healthcare facilities must implement written interim life safety measures (ILIMs) to address situations when the organization cannot immediately correct deficiencies� The policy should include criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased life safety risk� The facility must inspect exits in affected areas on a daily basis� It must provide temporary but equivalent fire alarm and detection systems for use during fire system impairment� Use smoke-tight temporary construction partitions made of noncombustible or limited-combustible material that would not contribute to development or spread of a fire� Increase surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices� Enforce storage, housekeeping, and debris-removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level� Provide additional training to those who work in the hospital on the use of firefighting equipment� Conduct one additional fire drill per shift per quarter� Inspect and test temporary systems monthly� The hospital must train those who work in the hospital to compensate for impaired structural or compartmental fire safety features�

1� What organization developed the CHEP credential? 2� Define the concept of an emergency as related to healthcare organizations� 3� When planning for emergencies and disaster, what approach must be used? 4� Describe the purpose and content of an effective hazard vulnerability analysis� 5� List the four phases of emergency management� 6� List six areas needing coordination that must be addressed in the EOP� 7� How often must Joint Commission-accredited facilities review the objectives and scope of

their EOP? 8� Describe the mission of the Partnership for Community Safety� 9� List the six key areas healthcare facilities should focus on when conducting planning

sessions� 10� Describe the purpose and process of the strategic national stockpile� 11� What publication should healthcare facility planners reference for pandemic planning? 12� When did the NFPA publish its First Edition of the Life Safety Code®? 13� How frequently must healthcare facilities conduct fire inspections for each zone? 14� In your own words, describe the concept known as fire confinement�