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FIRE AND EVACUATION PLAN
Revision 1999
Revision 2002
CODE RED
DIAL 62222
RESCUE
ALARM
CONTAIN
EXTINGUISH/
EVACUATE
Beth Israel Hospital – Needham Campus
Needham, MA 02492

FIRE PLAN
A Fire Plan has been assembled to provide for an organized plan in the event a fire occurs in the hospital. The basic Fire Plan calls for reporting a fire by the activation of the fire alarm system and/or by dialing extension 62222 and initiating an announcement over the P.A. system of its location ( CODE RED location, announced three times).
Every employee must read carefully and understand the procedure to follow in case they identify a fire emergency, and to follow his/her assignment in the event of a fire occurring.
Every employee must be vigilant in identifying potential fire hazards and be firesafety conscious.
Any evidence or suspicion of fire, no matter how insignificant, has been controlled by hospital personnel, or apparently burned out by itself, MUST BE
REPORTED IMMEDIATELY to the Maintenance/Engineering Department (ext.
33601), and Administrator or designee on duty.
Any active fire must be reported immediately by the activation of the FIRE
ALARM SYSTEM. No employee shall assume that a fire is too small to report.
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CODE RED PROCEDURE FOR ALL DEPARTMENTS
RESCUE patient, visitors, volunteers, or staff by removing them from the immediate vicinity of danger.
Announce " CODE RED ". Do not SHOUT "Fire".
Other employees in area will start the " CODE RED " procedure, closing windows and doors, getting fire Extinguishers, etc.
Act in a calm manner.
Sound ALARM All employees should be familiar with location of alarms in the working area. Upon pulling the alarm, the following occurs:
1. Alarm goes directly to Needham Fire Department, and they immediately respond to alarm.
2. The fire alarm also rings simultaneously in the towns of
Wellesley, Newton, and Dedham.
3. The alarm system is activated throughout the hospital.
4. Alarm enunciators located at the switchboard and in the
Emergency Department indicate the zone or approximate location of the CODE RED .
5. Smoke and fire doors close automatically.
If you use an alarm/pull box which is not located in the fire area, stand by the alarm box to give directions to employees and fire department responding.
TELEPHONE Dial EMERGENCY EXTENSION 62222, and inform switchboard operator as to location and type of fire.
CONTAIN the fire and the vicinity of the fire. Close all windows and doors.
The fire, heat and smoke should be confined and isolated to prevent their spread and to cut off drafts that will fan the flames. Close all doors and windows leading to fire area. Disconnect air conditioners and fans if possible.
EXTINGUISH the fire. Fight the fire only if the fire is small and contained
(as in the case of a wastebasket fire), and if you know how to operate a portable fire extinguisher. Before fighting even a small fire, be sure that the area has been evacuated and that the fire has been reported.
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When CODE RED is announced, follow these GENERAL FIRE RULES FOR
ALL DEPARTMENTS:
POINTS TO REMEMBER
Primary
1. Close all windows and doors.
2. Know where fire alarm pull stations and fire extinguishers are located.
3. Know the evacuation routes.
4. No unnecessary passing through FIRE AND SMOKE DOORS
Secondary during a CODE RED unless of an emergency nature.
5. Do not use elevators.
6. Know the different types of fire extinguishers and how and when to use them.
7. Any use of a fire extinguisher must be reported to Maintenance so that it can be recharged.
8. Do not shut off oxygen unless directed by Nursing Supervisor/Fire
Department.
9. Do not open doors leading to exits unless you are evacuating patients.
10. Do not obstruct exits, stairways, doors to rooms, or fire equipment.
OXYGEN
Oxygen zone valves should be shut down only under the authorization of the
Nursing Supervisor/Needham Fire Department. Nursing personnel should use their own judgment when a fire occurs in the vicinity of a patient with oxygen in use. The individual oxygen units in each patient room can be disconnected by pulling it out of the wall connector. By disconnecting in this manner, time is saved versus turning the oxygen off at the zone valve. When a portable unit is being utilized, the on/off valve must be turned off at the unit.
FIRE DOORS
There should be no unnecessary traffic through the smoke or fire doors.
HVAC SYSTEM
The Maintenance Department personnel will control the HVAC system upon order from the Fire Department personnel.
EVACUATION PROCEDURE
When fire threatens the safety of patients, staff, visitors or volunteers, the Beth
Israel Deaconess HospitalNeedham Campus may be instructed to evacuate on
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a partial or complete basis. The decision to evacuate will be based on the recommendation or order of the Fire Department, the Administrator, or his alternate. If the determine is made to evacuate the hospital or an area with the hospital, the Needham Fire Department shall direct and control the evacuation.
CONTROLLING FIRE
If the fire is small and confined to a small area - FIGHT IT. Make sure you or someone else initiates the CODE RED procedure.
FIRE EXTINGUISHERS :
CLASS A WATER PRESSURE TYPE
CLASS B DRY CHEMICAL AND CO2
Ordinary combustibles: wood, bedding, paper, clothing. (You can also drench a small class A fire with water or smother it with a blanket or sand.)
Flammable Liquids and Gasses:
Grease, paint, paints thinners,
propane, oil.
CLASS C CARBON DIOXIDE (CO2) Fires occurring in electrical
equipment motors, controls,
wiring or office machines.
When in doubt, use carbon dioxide (C) extinguisher. NEVER use water pressure extinguisher on electrical, oil or chemical fire. A multipurpose fire extinguisher
(ABC) can be used on all 3 major types of fire.
TO USE PORTABLE FIRE EXTINGUISHERS:
P P ull the pin.
A A im the nozzle at the base of the fire.
S
S
S
S queeze the handle. weep the nozzle back and forth, in a side to side motion.
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FIRE RULES FOR SWITCHBOARD OPERATOR
1. When the fire alarm sounds, read the enunciator (fireboard) to obtain location of CODE RED . If fire message is received by telephone, obtain exact building and floor location, extent and type of fire, if possible and who placed the call.
2. Call the fire department: #62255
#1096
#444-0142
Inform them of the exact building and floor location of the fire, and the extent and type of fire if possible.
3. Announce " CODE RED " and the location of the fire three times on the public address (PA) system.
4. Notify Administration and/or Administrator on-call.
5. Notify the Facilities Manager.
6. In all instances regarding authentic use of the fire procedure, the
Administrator and the Facilities Manager are to be called.
7. Announce "CANCEL CODE RED " (three times on the public address
system) only upon authorization of the Fire Department and/or person
conducting a Fire Drill.
*** From 9:00PM to 6:30AM Monday through Friday; weekends 9PM to 7AM the
Switchboard goes on Night Service. All incoming calls including in-house "0" and
"62222" go to the Emergency Department.
***The Emergency Department then follows all Switchboard procedures for a
CODE RED .
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INSTRUCTIONS FOR FIRE SQUAD
Employees assigned to the Hospital Fire Squad shall report to the scene of the
CODE RED with portable fire extinguishers. Do not use elevators. At the scene, they shall assist in controlling the fire and/or evacuating personnel until relieved by the Fire Department and/or person conducting a Fire Drill.
INSTRUCTIONS FOR MAINTENANCE
The Maintenance person on duty shall, (at the time of a CODE RED announcement) retrieve the Fire Department elevator by-pass key from Key cabinet #1. He shall then report to the location of the CODE RED alarm. At the scene, he shall report to the person in charge. He shall be readily available to assist the Fire Department with locating and identifying building service utilities, connections and shut-offs.
NOTE: THE OXYGEN ZONE VALVES SHOULD NOT BE SHUT OFF UNLESS
DIRECTED BY THE NURSING SUPERVISOR OR ALTERNATE, OR BY
DIRECT ORDER OF THE NEEDHAM FIRE DEPARTMENT.
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SPECIAL INSTRUCTIONS FOR DEPARTMENTS
ADMINISTRATIVE/OFFICES : (Admitting, Social Service, Human Resources,
Accounting, Materials Management, Library and other office staff).
1. Close all windows and doors.
2. Keep patients and visitors in these areas. Do not allow any passage through smoke or fire doors.
BUSINESS OFFICE (86 SCHOOL STREET ):
The Business Office located in a separate building at 86 School Street (the
House) shall follow the general procedures when identifying a Fire Emergency.
When a Fire Emergency is identified, the Evacuation Plan will be instituted. All staff and visitors should exit the building through identified vertical and horizontal exit routes. The PA system does not extend to the House; therefore, staff and visitors at the House would not participate in a Code Red announced in the main hospital.
CENTRAL SUPPLY :
1. Close all windows and doors.
2. Restrict movement through smoke or fire doors.
3. Turn off equipment being used.
COFFEE SHOP :
1. Close all windows and doors.
2. Restrict movement through smoke or fire doors.
3. Turn off equipment being used.
When fire is in the area follow general instructions. In addition:
1.
2.
3.
Shut off gas and all fans.
Evacuate the area through designated exit routes.
Close all doors as you leave area.
HOUSEKEEPING :
1.
2.
Close all windows and doors.
Designated employees report to FIRE SQUAD at scene.
3. Other employees remain at duty station and assist as requested.
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KITCHEN :
1. Close all windows and doors.
2. Designated employees report to scene with FIRE SQUAD.
3. Other employees remain in the department and await further instructions.
When fire is in the area follow general instructions. In addition:
1.
2.
3.
Shut off gas and all fans.
Evacuate the area through designated exit routes.
Close all doors as you leave area.
LABORATORY :
1. Close all windows and doors.
2. Restrict movement through the smoke or fire doors, hallway, and
South I stairwell.
3. All patients, visitors and staff should be escorted into the Rehab
Department until CANCEL CODE RED is announced.
4. On the 3-11 and ll-7 shift, when no patients are under their control, report to the scene of the CODE RED as a member of the Fire
Squad.
When fire is in the area follow general instructions. In addition:
1. Turn off fans, and non-essential electrical equipment.
2. Evacuate the area through designated exit routes.
3. Close all doors as you leave area.
4. See addendum Laboratory Fire Rules.
LAUNDRY :
1.
2.
Close all windows and doors.
Designated employees report to scene as Fire Squad.
4. Other employees remain in department and await further instructions.
When the fire is in the area follow general instructions. In addition:
1. Turn off equipment and window fans.
2. Evacuate the area through designated exit routes.
3. Close all doors as you leave area.
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MAINTENANCE :
1. Close all windows and doors.
When fire is in the area follow general instructions. In addition:
1. When fire is in the BOILER ROOM, shut off fuel pumps, and close the suction valves to the #2 and #4 oil tanks.
2. Do not attempt to fight any fires in the TRANSFORMER VAULT.
3. Do not shut down any systems unless directed by the Fire
Department and/or Nursing Supervisor, unless you KNOW it will not adversely affect direct patient care.
MEDICAL RECORDS :
1. Close all windows and doors.
MEDICAL STAFF :
In-house Medical Staff are requested to stay at their location and offer their assistance to the Department Manager.
NURSING PERSONNEL : (South I & II, MDC, Emergency Department, Same
Day Surgery, ICU)
1. Nursing personnel should remain at their assigned clinical areas. If they are with a patient in another area when CODE RED is broadcast, the Nursing personnel should remain with their patient until the CANCEL CODE RED is announced.
2. If it is necessary to inform patients, reassure them that the alarm has been turned in and that everything is under control.
3. Close all windows and doors securely and keep the patients in their rooms. Doors are constructed to withstand fire for an extended period.
4. Charge Nurse shall keep available a list of all patients to see that all are accounted for, and shall designate one nurse to prepare to evacuate, if directed.
5. Keep other employees, visitors, volunteers, and others in the Unit until the CANCEL CODE RED signal is announced.
*** Emergency Department - In the event the portable x-ray machine is in the ED hallway, staff will move it into a patient room.
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*** Medical Day Care - Patients in the MDC observation area must be moved into a patient room with a fire door.
OPERATING AND POST-ANESTHESIA CARE UNIT :
1. Close all windows and doors.
2. Keep all doors closed; make every effort to prevent spread of smoke.
3. Prepare patients for emergency evacuation from the Operating and
Post Anesthesia Care Unit.
When fire is in the area follow general instructions.
1. See addendum Operating Room Fire Plan
RADIOLOGY:
1. Close all windows and doors.
2. Restrict movement through smoke or fire doors keeping outpatients in the waiting area.
3. Keep in-patients in the department until CANCEL CODE RED is heard over the PA system.
4. On 3-ll and 11-7 shifts, if no patients are under their control, report to the scene of the CODE RED as a member of the Fire Squad.
REHABILITATION SERVICES:
1.
2.
Close all windows and doors.
Restrict movement through smoke or fire doors.
3. All employees, patients and visitors are to gather in the Department until CANCEL CODE RED is announced. This includes those in the waiting area.
When fire is in the area follow general instructions. In addition:
1. Turn off equipment.
RESPIRATORY THERAPY:
1.
2.
Close all windows and doors.
Therapist on duty will report to the scene of the fire.
3. Be prepared to assist as required with management of patients or as assist with evacuation.
VOLUNTEERS :
1. Upon activation of the fire alarm system, volunteers that may be involved in transporting a patient will seek an empty room nearby
(example: solarium, patient room), unless volunteer is accompanying nurse in an emergency situation.
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2. There will be no movement through any smoke or fire doors.
3. Remain in the area and out of the traffic flow until CANCEL CODE
RED is announced over the public address system.
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ORIENTATION, TRAINING AND EDUCATION OF STAFF TO FIRE PLAN
1. Individuals new to the organization including full-time, part-time, per-diem and contract employees and any others who will work within the hospital must be oriented to the Fire Plan preferably prior to performance of job duties, but no later than 30 days after employment begins.
Orientation shall address facility-wide response and department specific needs.
2. Continuing education for all employees will be provided to maintain knowledge of Fire Plan and to update skills, as necessary. Evidence of documentation must exist.
3. All staff will be expected to participate in Fire Drills. A critique of the Fire
Drill will immediately follow to evaluate effectiveness of training and to determine further training needs.
4. All staff shall be able to discuss their role in the Evacuation Plan to evaluate effectiveness of training and to determine further training needs.
5. Employees designated as members of the Fire Squad shall be educated to their specific duties, including use of portable fire extinguishers.
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FIRE DRILLS
This Fire Plan shall be tested by performing Fire Drills; which will encompass all personnel on all shifts in all patient care buildings, quarterly, conducting and evaluation of fire drills that test staff knowledge of the use and function of the fire alarm systems, transmission of alarms, containment of smoke and fire, transfer to areas of refuge, fire extinguishment, assignment of specific duties, and preparation of building evacuation.
FIRE PLAN HANDBOOK
Revision 1993
Revision 1995
Revision 1996
Revision 1999
Revision 2002
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LABORATORY FIRE RULES
Person discovering the fire:
1.
2.
Remove patients and personnel from immediate area of danger.
Activate the fire alarm box to alert others.
LOCATION OF FIRE ALARM BOXES: a. OUTSIDE MAIN LAB IMMEDIATELY AFTER THE
STAIRWELL, TOWARD THE EMERGENCY DEPARTMENT. b. OUTSIDE HEMATOLOGY AREA ON THE ELECTRICAL
PANEL. c. OUTSIDE THE MAIN LAB NEXT TO THE STAFF MEN'S
ROOM. d. OUTSIDE THE LAB DIRECTOR’S OFFICE.
3. Dial 62222 Emergency number. Give Operator: a. The exact location of fire an smoke. b. Your name.
4. Close all windows and doors to confine fire and smoke.
5. Turn off fans, nonessential electrical equipment.
6. Use extinguishers if this can be done safely.
7. Follow instructions from Fire Department, Director of Facilities,
Supervisors.
8.
9.
Follow laboratory evacuation route.
Close all doors as you leave area.
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OPERATING ROOM FIRE PLAN
Small Fire
Pat out or smother small fire, soak with saline, or remove immediately from patient. Later report circumstances to Charge Nurse. Make out Incident Report.
Large Fire
1. The Anesthesiologist will stop the flow of breathing gases to patient momentarily, if necessary. Patient can tolerate short period of air deprivation.
2. Remove burning material from patient. Apply WATER JEL BLANKET. a. Have another team member extinguish the burning material. b. If needed, use (water) extinguisher - preferably Halon to put out fire involving patient. Use saline on table.
3. During Daytime Hours (7-3 pm): If not quickly under control, circulator dials 62222 and gives location of the (OR Room # 1, 2, 3, or 4) .
Switchboard will notify Needham Fire Department and announce Code
Red - OR 1, 2, 3, or 4. Activate Emergency Lever (Red light appears on board in Emergency Department).
During Evening and Night-time Hours (3-11 7 11-7): Dial 169 -
Announce Code Red - OR three times. Dial 1096 directly to Needham
Fire Department. Activate emergency lever in Operating Room (Red light appears on board in Emergency Department).
4. Unplug electrical devices if they are involved.
5. Care for patient: a. Resume ventilation b. Control bleeding c. Evacuate if room is dangerous or full of smoke. d. Examine patient for injury and treat accordingly.
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OPERATING ROOM LARGE FIRE - EVACUATION
1. Report fire as stated previously.
2. Respond appropriately to fire. a. Shut doors to other Operating Rooms. b. Disconnect electrical plugs if involved. c. Activate extinguishers. d. Activate water gel blankets.
3. Use Evacuation routes under direction of Surgeon or Anesthesiologist. a. b.
Anesthesiologist turns machine off.
Ambu Bags in each room for Emergency Evacuation. c. Transport patient on OR table with endotube connected to ambu bag. d. Evacuation Route - Main corridor to main OR door to SDS.
SDS - When CODE RED OR is heard, plan to move SDS patients to
South II Solarium. Prepare SDS room to receive OR patients.
PACU - When CODE RED OR is heard - prepare to transport patients to
South II (will need people to transport). Eighteen (18) personnel from other areas needed to assemble at main OR door to transport patients.
Reviewed and Approved: Safety Officer
EOC Committee
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