Fire Prevention and Emergency Evacuation Plan

1

Fire Prevention And Emergency Evacuation Plan
2004
Hospital Support Services Department
Updated June 2004 to reflect new emergency codes
TABLE OF CONTENTS
I. Purpose ...... 1
II.Reference ...... 1
III.Accountability ...... 1
IV.Roles and Responsibilities ...... … 2
A.University Hospital Staff and Faculty ...... ….. 2
1.University Hospital Occupants...... 2
2.Department Manager/Nurse Manager or Designee …………………………………………………….. 3
3. Administrator-On-Call (AOC) or Patient Care Coordinator (PCC) ...... 4 4. University EOC Safety Committee ...... …………. 4 B. Public Safety Department ...... 4 1. The Dispatch Office . 4
2.On-Duty Security Officer(s) [C-level security desk]...... 5
3.Assigned Public Safety Officer(s)...... …………………………………………………………………………….6
4.On-Duty Public Safety Supervisor...... 6
C.Telecommunications (Emergency Operator: 111)...... 7
1. Fire Alarm Notification...... 7
2.“CODE RED” ("Dr. Firestone") Announcement ...... 7
3.“CODE RED ALL CLEAR” ("Dr. Clearwater") Announcement...... 7
D.UMDNJ Physical Plant...... 8
E.The University Hospital Environment of Care (EOC) Coordinator...... 8
F.Responding Fire Department...... 9
V.Emergency Procedures...... 9
A.Use of the Acronym “R-A-C-E” ...... 9
RESCUE ...... 10
ALARM ...... 10
CONTAIN...... 10
EXTINGUISH...... 11
1. Small Fires...... 11
2. Large Fires ...... 11
EVACUATE...... 11
1. Partial Evacuation...... 11
2. Lateral/Horizontal Evacuation...... 12
3. Vertical Evacuation...... 12
4. Complete Hospital...... 13
VI. Fire Watch Procedure...... 14
VII. Fire Drills...... 15
VIII. Training...... 16

A P P E N D I C E S
A.University Hospital Fire Drill Procedure
Attachment I. Fire Response Evaluation Check Sheet
Attachment II. Speed Memorandum
Attachment III. Fire Drill Form
Attachment IV. Fire Drill Schedule
B.Fire Extinguishers: Your First Aid to Firefighting
C.University Hospital Fire Safety Tips
D.Fire Emergency Procedures For Contractors/Subcontractors at University Hospital
E. FIRE SAFETY POLICY

UNIVERSITY HOSPITAL

FIRE PREVENTION AND EMERGENCY EVACUATION PLAN

I.PURPOSE

This plan provides appropriate fire prevention and emergency response procedures, and education for all occupants of University Hospital (UH). It will ensure safe and effective action in the event of a fire, and furnish information regarding the use and function of fire alarm systems; the containment of fire and smoke; partial emergency evacuation procedures; and fire extinguishment.

This plan outlines the responsibilities of University Hospital's in-house Emergency Responders, the responding Fire Department and other external agencies. All of the following are considered Emergency Responders at UH:

Administrator-On-Call

Patient Care Coordinator

Disaster Coordinator

Environment of Care Coordinator

Responding Public Safety Staff

Responding EOHSS Staff

Responding Physical Plant Staff

Responding Newark Fire Department

Other External Responding Agencies

II. REFERENCE

This plan complies with the fire safety requirements of the New Jersey Department of Community Affairs, the life safety aspect of the Americans with Disabilities Act, the Public Employees Occupational Safety and Health Act (PEOSHA) Emergency Evacuation Standard (OSHA 29 CFR 1910.38), the National Fire Protection Association Life Safety Code (NFPA 101, Section 31-4), and the requirements of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) environment of care standards.

III. ACCOUNTABILITY

The Vice President and Chief Executive Officer of University Hospital shall ensure compliance with this Plan. The Chief Executive Officer shall ensure overall coordination of this plan in conjunction with the Hospital Environment of Care Safety Committee. As every employee has a role in this Plan, each shall comply with its provisions and shall assume the responsibilities of their specified duties as outlined in this Plan.

IV. ROLES AND RESPONSIBILITIES

A.UNIVERSITY HOSPITAL STAFF AND FACULTY

1. UNIVERSITY HOSPITAL OCCUPANTS will:

·Comply with the UH fire safety policy (appendix E).

·Always pull the nearest fire alarm upon discovering a fire or smoke condition. After pulling the fire alarm, call the emergency number 222 (Public Safety Dispatch Office) from a safe location and identify the exact location and type of fire.

·In the event that the discoverer is unable to contact the Public Safety Dispatch Officehe/she will call the Newark Fire Department at (973) 733-7400 from a safe location.

·Upon hearing the fire alarm, closing all patient, office, laboratory, and utility room doors throughout the hospital.

·Listen for the “CODE RED” (“Dr. Firestone”) announcement to identify the location of the firealarm.

·Clear the corridors and elevator lobbies on the floor of the fire alarm and the floor above.

·Remain alert and await further instructions on the announcement system.

·Become familiar with the locations of the nearest emergency exits/stairwells, fire alarm pull boxes and fire extinguisher.

·Participate in all fire drills and actual fire alarm situations.

·Report all observed fire hazards and unsafe conditions to the Department/Unit which is responsible for remediation of the problem and/or to the EOC Coordinator (extension 2-3358).

In the event of a real fire, the Director of Hospital Support Service or designee will inform the New Jersey Department of Health at 1-800-792-9770.

For additional information: Contact the Environment Of Care Coordinator, at extension 2-3358 2004

FIRE PREVENTION SAFETY PLAN: UH1

2. DEPARTMENT/NURSE MANAGER OR DESIGNEE will:

- Go to their areas of responsibility and assist in the process of safe and systematic response to the alarmto include:

-Ensuring fire/smoke barrier doors, stairwell doors and windows are completely closed.

-Ensuring all other doors, including patient doors and office doors are completely closed.

-Directing wandering patients, visitors and staffon the floor of the fire alarm and the floor above to return to patient room and/or clinic area.

·Ensure that all Contractors/Subcontractors working in their department/area complete and post the "Fire Emergency Procedures for Contractors/Subcontractors at University Hospital” (reference Appendix D).

·Ensure that their staff members receive annual Fire Safety Training as required by the Environment of Care Safety Committee and in accordance with the Joint Commission on Accreditation of Healthcare Organizations and the New Jersey State Department of Community Affairs.

·Determine when evacuation of their area is necessary; follow the evacuation procedures as outlined in Section V, page 9.

·Notify the EOC Coordinator (2-3358) of all deficiencies, as they relate to fire safety.

·Become familiar with the area(s) for which they are responsible.

·Become familiar with the use and location of fire protection equipment.

·Monitor stairwells and doorsways to prevent unauthorized re-entry.

For additional information: Contact the Environment Of Care Coordinator at extension 2-3358 10/04

FIRE PREVENTION SAFETY PLAN: UH1

3.ADMINISTRATOR-ON-CALL (AOC) during normal working hours or PATIENT CARE COORDINATOR (PCC) beyond normal working hours will:

·Coordinate emergency response through Department/Nurse Manager.

·Determine need to declare the implementation of the Hospital Emergency Operations Plan.

·Identify and correct all observed unsafe conditions; and report any fire hazard to the Environment of Care Coordinator.

4.UNIVERSITY HOSPITAL ENVIRONMENT OF CARE SAFETY COMMITTEE will:

·Participate in quarterly fire drills for each working shift and maintain records as required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

·Monitor compliance with the provisions of this Plan.

·Review and update this plan at least annually in conjunction with the Environment of Care Coordinator.

B.PUBLIC SAFETY DEPARTMENT:

1.THE DISPATCH OFFICE will:

Upon receiving the fire alarm signal:

·Contact the On-Duty Security Officer (Main Entrance: C-Level Security Desk) by radio or phone, and request to find out the exact location of fire alarm.

·Notify Emergency Operator at extension 111 (Telecommunications Office in

MSB, A-549).

·Assign a Public Safety Officer for external traffic control.

For additional information: Contact the Environment Of Care Coordinator at extension 2-3358 10/04

FIRE PREVENTION SAFETY PLAN: UH1

Beyond the Normal Working Hours:

·Notify the Patient Care Coordinator in the event of fire emergencies.

·Notify the on-call Radiation Safety Officer in the event the fire emergency involves radioactive material.

2.ON-DUTY SECURITY OFFICER(S) [C-Level Security Desk] will:

·Go to the fire alarm annunciator panel located on C-Level, and read the location of fire.

·Report the location of fire alarm promptly to the Dispatch Office.

·Report any other information, as received, to the Dispatch Office.

·Clear the main entrance corridors and elevator lobbies on C Level.

·Control traffic to and from stairwells 4 and 6 on C Level.

·Control Elevators:

(a) Recall both passenger and patient elevators to the designated level; and,

(b) Make the elevators available to the Fire Department/Emergency Responders for firefighting and evacuation.

1. Freight elevators will be manually recalled to C-Level by Public Safety and/or

Physical Plant.

·Assist Fire Department and other responding external agencies.

·Direct incoming traffic of people.

·Allow anyone declaring an emergency to enter the Hospital and/or use the elevator as needed. Record the names of such individuals and nature of emergency to properly manage traffic.

For additional information: Contact the Environment Of Care Coordinator at extension 2-3358 10/04

FIRE PREVENTION SAFETY PLAN: UH1

·Maintain an up-to-date copy of this Plan at the Security Desk for reference.

·Provide a two-way radio with the UMDNJ Physical Plant frequency to the responding Fire Department.

3.ASSIGNED PUBLIC SAFETY OFFICER(S) will:

·Keep the fire lane clear of traffic for the Newark Fire Department's use.

·Control street traffic, as required.

·Keep evacuated people at least 50 feet from the building.

·Inspect and maintain the two-way radio and charger on a regular basis for use by the responding Newark Fire Department.

4.ON-DUTY PUBLIC SAFETY SUPERVISOR will:

·Set up a command post in a safe location (inside or outside) of the Hospital in the event of emergencies that will require implementation of prolonged response procedures. The command post will serve as a central point of control, including reporting to internal and external agencies. Information to the media will be provided through the Hospital’s Media Relation Department.

·Assist in smooth operation of the Command Post, as required.

·Ensure that adequate Public Safety Officers are assigned for external traffic control, and for handling fire related emergencies.

·Implement "Fire Watch" rounds in areas recommended by the Newark Fire Department, Physical Plant, EOHSS and /or the Hospital Support Services Department. The "Fire Watch" procedure is outlined in Section VI.

·Participate in post-fire briefing to evaluate response.

For additional information: Contact the Environment Of Care Coordinator at extension 2-3358 10/04

FIRE PREVENTION SAFETY PLAN: UH1

·Notify the Telecommunications Department of the “ALL CLEAR” after notification from Physical Plant that the fire alarms and air handlers have been re-set.

C.TELECOMMUNICATIONS OFFICE:

This office is located in the Medical Science Building, Room A-549. It is equipped with two emergency phones: Extension 111, and Paging System #2-6000. Both of these numbers are operated by the same Operator. The Public Safety Department notifies the Operators of the exact location of the alarm.

1.UPON RECEIVING FIRE ALARM NOTIFICATION FROM PUBLIC SAFETY, THE OPERATOR will notify ( in order):

• The Newark Fire Department at (973) 733-7400 to confirm receipt of alarm.

• The Physical Plant Work Control Center at 2-5400.

2.“CODE RED” ("Dr. Firestone") ANNOUNCEMENT:

The fire alarm system for University Hospital is also directly connected to the Telecommunications office located in the Medical Science Building, Room A-549. As soon as the fire alarm notification is received from Public Safety, the Telecommunications Department will announce three (3) consecutive times over the Hospital P.A. system:

“COD RED” (“Dr. Firestone”), Report to (location of affected area). All patients, staff and visitors on (floor of the fire alarm and floor above) are reminded that they must clear the halls and remain in their present location unless otherwise instructed.

3.“CODE RED ALL CLEAR” ("Dr. Clearwater") ANNOUNCEMENT:

Upon notification from Public Safety Dispatch Office in conjunction with the Newark Fire Department that the fire alert/emergency is over and/or the alarm/ventilation system has been reset, the Telecommunications Department will announce three (3) consecutive times over the Hospital P.A. system:

“CODE RED ALL CLEAR” ("Dr. Clearwater”), Report to (location of affected area)"

For additional information: Contact the Environment Of Care Coordinator at extension 2-3358 10/04

FIRE PREVENTION SAFETY PLAN: UH1

D.UMDNJ PHYSICAL PLANT will:

·Be notified of building, zone and location of fire or smoke related incidents via Public Safety Dispatch Office and/or the Operator.

·Assist both the internal and external emergency responders in controlling the emergency situation (e.g. Heating, Ventilation and Air Conditioning controls, electrical power control, etc).

·Reset fire alarms and/or air handlers after the initial clearance is given by the responding Newark Fire Department.

·Notify Public Safety Department of the "All CLEAR".

·Participate in post-fire briefing and address issues related to fire alarm system.

·Inspect/Maintain fire protection and emergency response systems including:

-Fire Alarm- Sprinkler System

-Heat/Smoke Detection System- Hydrant/Standpipe System

·Notify Public Safety and the Environment of Care Coordinator of all conditions (e.g., fire alarm system not working) and activities (e.g., repair, maintenance, etc. of fire alarm system) that may reduce the effectiveness of fire protection and/or emergency evacuation process.

·Initiate a "Fire Watch" procedure for the affected areas as outlined in Section VI.

·Promptly report all maintenance and renovation projects that may reduce the effectiveness of the fire protection and/or emergency response systems to the office of the New Jersey State Bureau of Fire Safety.

E.THE UNIVERSITY HOSPITAL ENVIRONMENT OF CARE COORDINATORwill:

·Coordinate necessary fire safety education and training.

·Investigate/analyze evacuation incidents and evaluate response.

For additional information: Contact the Environment Of Care Coordinator at extension 2-3358 10/04

FIRE PREVENTION SAFETY PLAN: UH1

·Develop and maintain a "Fire Prevention and Emergency Evacuation Plan” to reflect updated changes in the use and physical arrangement of the building.

·Oversee the Hospital’s fire extinguisher program.

·In conjunction with the Environment of Care Safety Committee, coordinate fire drills, maintain records and review this Plan on at least an annual basis.

F.RESPONDING FIRE DEPARTMENT will:

·Respond immediately upon receiving a fire alarm signal or telephone notification.

·Assume responsibility of the response operation upon arrival on the scene.

·Obtain detailed incident information and support from the Public Safety Officer, Director of Hospital Support Services and/or other emergency responders.

·Assist in emergency evacuation as necessary.

·Give clearance to UMDNJ Physical Plant to initiate reset of fire alarms and ventilation systems in preparation for the final "ALL CLEAR".

·Return two-way radio to Public Safety after emergency response is complete.

All Emergency Responders will follow the directions of the responding Fire Department.

V. EMERGENCY PROCEDURES

A.USE OF THE ACRONYM R-A-C-E

If a fire or smoke condition is discovered: Alert those in your immediate area and

implement “RACE”.

 R=Rescue

 A=Alarm

 C=Contain

 E=Extinguish

or Evacuate

The acronym “RACE” is used throughout University Hospital to remind staff and personnel of the proper procedures for response during an actual fire or smoke condition.

RESCUE

· All patients, visitors and/or staff members that are in immediate danger only should be rescued if the situation does not pose a threat to the rescuer. Leave “other rescues” for the responding Fire Department to handle as they have the appropriate personal protection equipment for such situations.

 ALARM

· Manual fire alarm pull boxes are located throughout University Hospital. Any person who discovers (or suspects) fire or smoke, will proceed to the nearest pull box, and pull the alarm. Pulling any one fire alarm pull box will activate alarms on all levels of theHospital. If you suspect a fire, always pull the pull box. It will take approproximately 5 seconds after the alarm has been pulled for the alarm to sound.

·If the alarm does not sound, pull another fire alarm box. If alarm is still not heard, call the fire safety emergency number 222 or 2-4490 (Public Safety Dispatch Office) from a safe location and identify details and the exact location of fire.

·In the event that you are unable to contact Public Safety Dispatch Office, call the Newark Fire Department at (973) 733-7400 from a safe location and identify the exact location and type of fire.

·The fire alarm system for University Hospital is directly connected to the Newark Fire Department. Therefore, fire alarm signals are automatically transmitted to the Newark Fire Department.

·After notification, the Telecommunications Department will announce “CODE RED” (“Dr. Firestone”).

CONTAIN

·In an area where there is an actual fire, shut the doors, windows and fume hood sashes wherever possible. This will prevent the fire or smoke from spreading.

·In other areas, the staff will also attempt to do so throughout the hospital to

prevent the fire or smoke from spreading.

·Do not open any door that feels hot. Opening such doors might result in increased fire spread.

·Turn off all unnecessary non-patient support electrical and gas equipment, including computers.

EXTINGUISH

1.SMALL FIRES:

·Hospital occupants will use fire extinguishers only for small fire-defense, i.e. waste paper basket, and only if they are trained and confident of their use, (reference Appendix B). Never attempt to fight a large or spreading fire with a portable fire extinguisher(s).

·Do not try to access fire inside a closed area by opening a door. Do not attempt to open any door in an effort to fight the fire with an extinguisher.

·In the event that an extinguisher is used, or is discovered in a discharged condition, promptly report this to the C Level Security Desk and/or the EOHSS Department at extension 2-4812 so that it can be replaced.

2.LARGE OR SPREADING FIRES :

The responding Fire Department will handle all large or spreading fires.

For additional information: Contact the Environment Of Care Coordinator at extension 2-3358 10/04