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Code Red - Fire Response Plan

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PURPOSE
In order to assure the safety of patients, visitors, and staff, a standard response to fire, or to the potential of fire, defined plans are required.  This fire plan describes the standard responses for all staff within Lander Regional Hospital to an activation of the Fire Alarm or to conditions that indicate the presence of a fire in the area.

POLICY
In the event of a fire, the staff and licensed independent practitioners will follow the basic plan for the building in which they are located.  They will use the same plans for fire drills as they do in actual events.  Fire drills will be observed to measure the effectiveness of staff response, as well as to measure the response of building fire systems.

PROCEDURE

1. Code Red or In Your Work Area

Hospital:
a.An alarm will sound throughout the building and where the pull station was activated or where the automatic sensors have detected smoke or heat. 
b.An overhead page will follow indicating the location of the fire.
c.If you discover smoke, fire, or the alarm system is activated in your immediate area, the appropriate response will best be remembered by using the acronym R.A.C.E.:

R- Rescue/Remove people
Remove anyone in immediate danger to a safe area. This may be a patient, visitor, or employee.
Do Not Use Elevators.

A- Activate Sound the Alarm
Go to the nearest pull station and activate. This notifies the Fire Department.
Call 444 to notify the operator of the location of the fire or 6300 after hours. The operators will then overhead page “CODE RED, Building, Area, and Location” three times at until ALL CLEAR then ALL Clear will be announced three times overhead. 

Note: Drills conducted between 9:00pm and 6:00am will only be announced one time until All Clear. 

C- Confine/Secure the Area
Close all doors and windows
Remove all items from the corridors
The Nursing coordinator, Maintenance, or Respiratory will assess the need if oxygen supply to the affected area should be discontinued.  Only the Nursing coordinator, Maintenance, or Respiratory are authorized to order a supply valve closed.  A member of the Nursing coordinator, Maintenance, or Respiratory will be responsible for closing the valve after ensuring all persons dependent on oxygen delivery systems are properly cared for. 

NOTE: With the exception in Surgery areas only, the Anesthesia personnel will turn off the oxygen.

E- Extinguish - Attempt to extinguish fire
Fight the fire only if you are not placing yourself in danger.
Personnel in the immediate department area should take an extinguisher and proceed to the fire. 

All Clear - Situation is under control
The Fire Department Incident Commander at the scene verifies that the situation has been resolved.  The Incident Commander will notify the Switchboard operator and “CODE RED, IS ALL CLEAR” will be paged overhead. 

2.General Responsibilities for Fire Alarm Activation Above, Below or Adjacent to the Code Red 

If your area is above, below, or adjacent to the point of origin, the following procedures are:

i.Close all doors
ii.Remove items from the corridors
iii.Have patients return to their rooms
iv.Remind patients and visitors not to use elevators
v.Listen for overhead pages for status of situation

3.General Responsibilities for Fire Alarm Activation Remote from Your Work Area

If your area is away from the point of origin (not within your immediate area or above, below or adjacent to that area), the following procedures will need to be implemented:
i.Be ready to accept patients from the point of origin
ii.Remind patients and visitors not to use elevators
iii.Listen for overhead pages for status of situation

4.Evacuation

a.Evacuation will not take place until directed by the Incident Commander and/or Fire Department. At any time, when several patients are in immediate danger, moving them to a safer area can be done without these approvals. Administration, Nursing Coordinator, or the Safety Officer evaluates the situation and determines the need to activate the Emergency Operations Plan.
b.Do Not Use Elevators
c.There are several types of evacuations, the following are the:

i.Stage I- Horizontal- move them into an adjacent smoke compartment.

ii.Stage II- Vertical- move one floor down taking the exit stairs.

iii.Stage III- Building- all patients and visitors will be moved from the building to alternate care sites. These sites are:

1.Wyoming State School (Primary)
2.one of the nursing homes (Secondary)

d.Incident Commander in conjunction with fire department or the police department, will determine the need for evacuation beyond horizontal evacuation to an adjacent smoke compartment.

For more information on evacuation, see Emergency Operations Plan - Appendix 1: Evacuation Plan.

5.Fire Response Team

The fire response team is made up of administration, maintenance, security respiratory and information services.  They are responsible for responding to the area when a code red is initiated. The Nursing Supervisor or designee will direct the fire response team once they arrive on the scene. 

6.Code Red or Code Red Drill In Business Occupancies 

Freestanding or Attached Buildings other than the Hospital:
a.An alarm will sound on all floors where the pull station was activated or where automatic sensors have detected smoke or heat.
b.An overhead page will indicate the location of the fire. 

c.If you discover smoke, fire, or the alarm system is activated in your immediate area, the appropriate response will best be remembered by using the acronym R.A.C.E.:

R – Rescue/Remove people
Remove anyone in immediate danger to a safe area. 
This may be a patient, visitor, or employee. 
Do Not Use Elevators.

A – Alert/Sound the Alarm
Go to the nearest pull station and activate. This activates the Fire Department.
Call 444 to notify the switchboard operator of the location of the fire. The operator will overhead page “CODE RED, Building, Area, and Location” three times until ALL CLEAR and/or
Call 911 to notify them of the location of the fire. Then overhead in your building, “Please evacuate the building at the nearest exit and meet in the (designated area)”.

C – Confine/Secure the Area
Close the door to the area where the fire or smoke is located.  
Leave all other doors unlocked and open, if possible. 
The designated floor captains will check the floor assuring that all personnel are evacuated.

E – Extinguish/Attempt to extinguish fire
Fight the fire only if you are not placing yourself in danger.

AND

E – Evacuate/Evacuation
Everyone must evacuate from these buildings immediately. 
Meet in the designated area
Do Not Use Elevators, if applicable. 

All Clear/Situation is under control
The Fire Department at the scene verifies that the situation has been resolved and whether staff may return to the building. 

7.  FIRE EXTINGUISHERS

a.Location of Fire Extinguishers:

All employees should be oriented to the location of the fire extinguishers in their respective work area/department.  Storage or equipment should never block fire extinguishers.  The maintenance department visually inspects extinguishers every month.

b.Use of Fire Extinguishers:

Select the proper fire extinguisher for the fire.  Position yourself as close to the fire as safely possible.  Remember to leave a way out. 

Use the PASS method to extinguish the fire:

Pull - the pin on the extinguisher.  

Aim - the extinguisher nozzle at the base of the flames.

Squeeze the handle to discharge the extinguisher.  Squeeze the handle as the contents are under pressure. 

Sweep from side to side at the base of the fire.  Remember that the extinguisher will empty quickly.  Do not waste the extinguishing agent.  

DO NOT ATTEMPT TO EXTINGUISH THE FIRE IF IT IS TOO LARGE OR DANGEROUS.  CLOSE THE DOOR, LEAVE THE AREA AND AWAIT ARRIVAL OF THE FIRE DEPARTMENT.

8.Fire Drills Will:

Be conducted a minimum of once per quarter per shift.
Be evaluated for performance of fire safety equipment and staff.
Be reviewed by the Environment of Care (EOC) Committee on a regular basis.
Simulate real-life possibilities.
Be scheduled at varied times.
Be conducted by the maintenance department
Be observed from varied locations.

Evaluation of Staff Knowledge will include:
Compartmentalization and containment.
Areas of Refuge.
Fire extinguishment.
Fire response duties.
Vertical and horizontal evacuation.

Staff response will be observed at the drill location and:
Adjacent compartment(s).
The compartment above and below the drill location.