CODE RED --Followed by message on display (which is location of fire/potential fire)

Transcription

1 FirstHealth Montgomery Memorial Hospital Policy and Procedure Page 1 of 26 Policy Number: Originating Department: Safety Committee Affected Department(s): All Departments Department Director Approval: Origination Date: Revision Date: Reviewed Date: Administration Approval: I. ACTIVATION OF SYSTEM A. The facility s fire alarm system is automatically activated by smoke and heat and manually by pull station. B. When the system is activated, digital displays (located at ED Switchboard office, Acute Care/Swing Bed Nurses Station, Maintenance Department, and Data Support Office) will show the location of the smoke detector activated or the area of the pull-station activated. C. When this occurs, the Switchboard Operator (Registration staff after hours) will broadcast the following message over the paging system and notify Security. CODE RED --Followed by message on display (which is location of fire/potential fire) This announcement will be repeated three (3) times. After an approximate 15 second pause, the message will be repeated two (2) additional times. D. The alarm system automatically (through a monitor control system) notifies the local fire department. It is not necessary to call 911. INSTRUCTIONS FOR IMMEDIATE RESPONSE IF FIRE/POTENTIAL FIRE IS DISCOVERED A. Utilize the acronym RACE as a reminder of necessary action in the event of a fire: Rescue patients in immediate danger Alarm (Activate nearest pull-station) Contain the fire; close doors, windows, etc., in immediate area of fire Extinguish the fire if this is feasible or Evacuate if necessary B. Once patients are removed from danger and alarm has been activated, return to the location of the fire with a fire extinguisher. Feel the door; if it is hot -- DO NOT OPEN IT; wait for the fire department to arrive. If the door is warm -- open it slowly and be prepared to use the fire extinguisher. C. Do not panic; the greatest danger in any fire is panic caused by fear, noise or smoke. NEVER SHOUT FIRE!! Remain calm and keep patients, visitors and other employees calm.

2 Montgomery Memorial Hospital Policy and Procedure Page 2 of 26 I STAFF RESPONSE TO CODE RED A. Upon hearing CODE RED and/or fire alarm, the following persons (at a minimum) shall secure a fire extinguisher (from their area) and report to the scene of the fire: Location of Fire Staff to Report First Shift: 1. All fires Maintenance staff in-house 2. First floor 1 person from Dietary Department 3. Second floor 1 person from Administrative Office Area 4. Third floor 1 person from Health Information Management Second Shift: 1. All fires 1 person from Imaging 1 person from Lab 1 Security Guard IV. 2. If fire in Imaging or 1 person from Acute Care Lab 1 person from Cardiopulmonary 1 Security Guard Third Shift: 1. All fires 3 rd floor Patient Care Technician Unit Supervisor 1 person from Cardiopulmonary 1 Security Guard PULL STATION LOCATIONS AND ALARM SYSTEM SIGNALS A. Pull-stations are located: First Floor: Conference Room One at exit door Hallway at rear entrance across from Facility Services break room Rear stairwell entrance at Environmental Services Break Room Front (Main) Lobby Front stairwell next to Administrative Offices Information Systems Office at exit door Second Floor: North stairs, west corridor (near Rm. 200) South stairs, west corridor (near Rm. 220) Center stairs, east corridor (near Med/Surg Nurses Station) Cafeteria corridor Emergency Dept. entrance Emergency Dept. Registration hall entrance Dietary Dept. exit to loading dock 2nd floor Cardiopulmonary Operating Room (by rear exit) Outpatient exit door (by Nurses Station) Outpatient Waiting Area Outpatient Hallway by Unassigned Outpatient Area Imaging Unassigned Outpatient Area Laboratory

3 Montgomery Memorial Hospital Policy and Procedure Page 3 of 26 Third Floor: North stairs, west corridor (by Rm. 300) South stairs, west corridor (by Rm. 320) Center stairs, east corridor (near Nurses Station) Activity Room (at fire exit) B. There are three (4) digital fire alarm read-out panels, which detail the location of any potential fire. These are located: 1. Data Support Office (first floor) 2. Third Floor Nurses Station (Acute Care) 3. Mechanical Room adjacent to the rear loading dock 4. ED Registration Office V. CLASSES OF FIRES and USE OF FIRE EXTINGUISHERS A. Classes of Fires: CLASS A: Combustible materials (wood, paper, cloth, etc.) CLASS B: Flammable liquids (kerosene, gasoline, etc.) CLASS C: Electrical equipment (any item plugged into or wired directly to an electrical source) B. Types of Fire Extinguishers: 1. Multipurpose dry chemical extinguisher Usually labeled ABC Designed to extinguish all 3 types of fires (A, B, and C) May be used on a patient but protect the face from the chemical 2. Carbon dioxide (CO2) extinguisher Usually labeled BC Designed to extinguish Class B and Class C fires Do NOT use on a patient 3. Pressurized water extinguisher Usually labeled A Designed to extinguish Class A fires May be used on a patient but place finger over nozzle to break the force of the stream of water 4. Type K Usually labeled Type K Used on grease fires in kitchen area Used as a secondary use of extinguishing 5. Water Mist Located in the MRI Mobile Unit MRI or Nuclear Medicine Mobile Unit * ONLY USE water mist or CO2 extinguisher Water mist extinguisher is located in the MRI mobile unit CO2 extinguisher is located at the ED sliding glass door exit by the nurses station * DO NOT USE ABC extinguisher

4 Montgomery Memorial Hospital Policy and Procedure Page 4 of 26 CT Scan Use CO2 extinguisher located inside the CT room by the door ABC extinguisher may be used as last resort Computer/IS Room Equipped with auto extinguishing system CO2 extinguisher located by the door ABC extinguisher may be used as last resort Kitchen Automatic extinguishing system for cooking areas Type K located by the entrance door to the kitchen (2) CO2 extinguishers also located in kitchen area C. How to Use a Fire Extinguisher: Use the acronym PASS to help remember proper use of a fire extinguisher: P - Pull the pin A - Aim the nozzle at the base of the fire S - Squeeze the handle S - Sweeping motion aimed at base of the fire VI. GENERAL INSTRUCTIONS FOR EVACUATING PATIENTS IF THIS BECOMES NECESSARY (See also EVACUATION PLAN for more details) A. Remove patients in immediate danger as per the RACE acronym. B. Do not evacuate until told to do so by the Chief Nursing Officer/designee, President/Administrative Staff member on-call and/or the fire department. C. If evacuation is ordered, move patients in the following order: 1. Those nearest the fire 2. Ambulatory patients (those who can walk; patients should be wrapped in blankets and led to and then down the fire exit stairs located farthest from the fire) 3. Non-ambulatory/helpless patients not in immediate danger; should be wrapped in blankets and moved: a. By stretcher b. By wheelchair c. In beds d. On mattress, blankets or sheets. e. By Med Sled or Med Chair D. Patients should be moved away from the fire and down, depending upon the level of evacuation ordered; see Evacuation Plan. E. If smoke is dense, or no other means of transportation is available, place blankets, sheets or any combination of these items on the floor to make a pad; slip corner of mattress off the bed and onto the

5 Montgomery Memorial Hospital Policy and Procedure Page 5 of 26 floor, and drag patient onto the pad. Place a pillow under the patient s head and pull him from the room and to the fire stairs. NOTE: Evacuation plan also contains more detailed information regarding methods of lifting, moving, etc. patients. F. In the event that patients are cut off from all exits, they should be taken into one room if possible; close door and wait for the fire department for help. Wet towels should be placed around the door to minimize smoke in the room. A sign of some sort should be placed at the window to let the fire department know that people are in the building. G. Patient records must also be evacuated if this is possible. H. Nursing personnel are responsible for monitoring and checking patients assigned to them before, during and after moving. I. Extreme care should be taken to ensure that all patients, visitors and staff are accounted for. V OXYGEN SHUT-OFF The Chief Nursing Officer (CNO) /designee or the Unit Supervisor on duty, in conjunction with CP personnel if feasible, is responsible for the shut-off of the area control valves (except OR area, which will be shut off by OR staff when the OR is open/running). Cardiopulmonary department staff is responsible for controlling the main O2 supply. VI OTHER GENERAL INFORMATION A. Upon hearing the alarms and announcements that Code Red is in effect, employees are to report to their own departments and follow instructions as per department-specific plan. Also, assistance may be necessary in other areas of the hospital. Housekeeping staff assigned to nursing floors will report to the Nurses Station in their work area and await instructions. B. Know the location of fire pull-stations and fire extinguishers in your work area and be sure you know how, when and where to use this equipment. C. DO NOT USE ELEVATORS!! D. It is conceivable that the Code Red and Code Triage (Mass Casualty/Disaster) plans could be enacted in conjunction with one another. This decision will be made by the Disaster Coordinator on duty as per the Code Triage Mass Casualty Plan. Please refer to that document for further information/instructions. E. In the event that telephone and intercom services are interrupted, departments are instructed to send nonessential personnel to the Incident Command Center (2 nd floor nursing station) for assignment.

6 Montgomery Memorial Hospital Policy and Procedure Page 6 of 26 IX. TERMINATION OF CODE RED STATUS The switchboard operator will be notified (by Safety Officer, Facility Services, Security, Chief Nursing Officer, Unit Supervisor, President/Administrative personnel on call or fire department) when the fire is no longer a danger. At this point, the switchboard operator will be authorized to page Code Red is Clear three (3) times over the intercom system. Refer to the Emergency Communication Plan if the intercom system is not functioning. X. DEPARTMENT-SPECIFIC PLANS The remainder of this document contains plans specific to each department/unit. Individual Departmental Code Red Fire Plans Table of Contents Administration 7 Cardiopulmonary... 8 Environmental Services. 9 Facility Services. 10 Family Care Center Troy 11 Food and Nutrition. 12 Health Information Management Laboratory.. 14 Nursing Units Operating Room / Anesthesia Services Pharmacy 19 Physical Therapy / Rehab Services 20 Purchasing Department.. 21 Quality Radiology / Imaging Registration 24 Security Guards.. 25 Switchboard... 26

7 Montgomery Memorial Hospital Policy and Procedure Page 7 of 26 ADMINISTRATION A. RACE B. Close all doors and file drawers. C. Turn off all electrical equipment. D. Follow instructions in general plan. FIRE OCCURS IN ANOTHER AREA OF THE HOSPITAL: A. Carry out above instructions. B. Secure Administrative area and assist as needed throughout facility, including sending a staff member to the switchboard if it becomes obvious that switchboard, telephone and/or intercom systems are not functioning. C. If the fire is on second floor during regular office hours, one person from the Administrative area is to secure a fire extinguisher and report to the scene of the fire.

8 Montgomery Memorial Hospital Policy and Procedure Page 8 of 26 CARDIOPULMONARY DEPARTMENT A. RACE B. Close all doors and file drawers. C. Turn off all electrical equipment. D. Remove patient records. E Follow other basic instructions. F. Turn off all oxygen and remove oxygen tanks. Ensure the availability of portable O2 tanks in the event needed for patients on oxygen. FIRE OCCURS IN ANOTHER AREA OF HOSPITAL: A. Close all doors and file drawers. B. Report to the room of any patient(s) on ventilator and assist with evacuation if this becomes necessary. C. If fire occurs on 2nd or 3rd shift, Cardiopulmonary personnel are to respond to all fires with a fire extinguisher.

9 Montgomery Memorial Hospital Policy and Procedure Page 9 of 26 ENVIRONMENTAL SERVICES Since Housekeeping personnel are not confined to any one area, the following instructions should be followed: o o o Remain in your own work area and follow instructions of the supervisor or person in charge. Help close doors and windows, evacuate patients as necessary and perform other duties as assigned. Be prepared to remove extra blankets from linen closets in case of evacuation.

10 Montgomery Memorial Hospital Policy and Procedure Page 10 of 26 FACILITY SERVICES In the event that Security needs to leave the building, they should check out with the ED Charge Nurse and Switchboard. When Security is out of the building the Switchboard will need to call the Facilities staff member on call when needed. The Maintenance Department is expected to assist all departments if there is a fire in or near the hospital. It is necessary for all Maintenance personnel to familiarize themselves thoroughly with the buildings and their construction. I. THE FOLLOWING IS A GUIDE THAT CAN BE USED FOR THIS PURPOSE: A. Know location and number of all fire alarm stations in the building. B. Know location of all fire extinguishers. C. Know how and what type extinguisher to use on each type of fire. D. Know where and how to cut off sprinkler system in the electrical equipment room on 1 st floor. E. Know how to operate switch gear in mechanical room. F. Know location of all exits. G. Know location of gas valves (oxygen, nitrous oxide, etc.) H. Know location of all electrical switch panels. I. Know location of water valves for building. FIRE OCCURS IN YOUR AREA: A. Rescue, Alarm, Contain, Extinguish I IN THE EVENT OF A FIRE: A. The following is a guide for a safety check in the event of fire: 1. Go to the area of the fire in an orderly manner. 2. Close all smoke and barrier doors you pass. 3. Locate fire. a. If the fire is near bottled gases, remove gases immediately. b. If the fire is in or near a light fixture, shut off electricity immediately. c. If fire is in portable electric equipment (electrical bed, suction machines, etc.), remove electrical cord from outlet, assess the extent of the fire (i.e., smoking wires versus flames) and take appropriate action to control the situation. 4. If the fire department is called, see that stairs and corridors are clear for firemen to enter. 5. Maintenance personnel will not concern themselves with the moving patients until a safety check of the area has been made, unless there is a patient in immediate danger.

11 Montgomery Memorial Hospital Policy and Procedure Page 11 of 26 FAMILY CARE CENTER - TROY A. RACE (Rescue, Alarm, Contain, Extinguish) Staff member discovering the fire assists in rescuing any patients or staff in immediate danger, and ensures that the nearest fire alarm pull station is activated. When the alarm is pulled, the security system automatically reports the fire to Security Central and the local fire department is notified. B. Evacuation process (in conjunction with closing all doors, windows, drawers and turning off all electrical equipment): Exam rooms/modules nurses and providers X-ray area x-ray techs Lab area lab techs Waiting room front office staff Clinic Manager/Site Coordinator or designee ensures complete evacuation of patients and staff Receptionist gathers the patient rosters for accountability of patients Patients and staff assemble in front of the lower Medical Arts Center entrance Receptionist takes roll of patients. Clinic Manager/Site Coordinator or designee takes roll of staff. Any missing/unaccounted for persons are reported to fire personnel. Staff is not to re-enter the clinic. C. NOTE: CO2 fire extinguishers are to be used for computer fires. ABC extinguisher may be used as last resort.. FIRE OCCURS IN ANOTHER AREA OF THE HOSPITAL: A. Carry out above instructions as authorized. Remain in your area to assist as needed and await further instructions from your supervisor or Administration. B. If it becomes obvious that the switchboard, telephone and/or intercom system is not functioning, send a staff member to the switchboard to assist as messenger.

12 Montgomery Memorial Hospital Policy and Procedure Page 12 of 26 FOOD/NUTRITION SERVICES A. RACE B. Use fire extinguisher to put out the fire if possible. Locations of fire extinguishers are: Near door by dish room entrance Near the dining room door Near the rear loading dock exit C. Close all doors/windows. D. Turn off all electrical equipment, appliances, motors, fans, lights, etc. E. If electricity is off in your area, open panel boxes located in the hall near the main door and turn off all switches. F. Report to Dietary Manager/Supervisor on duty and remain in the department until all employees are accounted for. If the fire is uncontrollable, evacuate the department into the dining room or hallway. FIRE OCCURS IN ANOTHER AREA OF HOSPITAL: Close all doors and windows. Turn off all electrical equipment, motors, fans, lights, appliances, etc. If it becomes obvious that the switchboard, telephone and/or intercom system is not functioning, send a staff member to the switchboard to assist as messenger. Available staff may be asked to assist with patient/resident evacuation or relocation if necessary. If the fire is on first floor during first shift, one person from the Dietary Department is to take a fire extinguisher and report to the scene of the fire. (USE STAIRS.)

13 Montgomery Memorial Hospital Policy and Procedure Page 13 of 26 HEALTH INFORMATION MANAGEMENT A. Rescue, Alarm, Contain, Extinguish B. Close all doors and file drawers. C. Turn off all electrical equipment, lights, etc. D. Move Master Patient Index to a safe area if possible. FIRE OCCURS IN ANOTHER AREA OF HOSPITAL: A. Turn off all electrical equipment. B. Close all doors and file drawers. C. If it becomes obvious that the switchboard, telephone and/or intercom system is not functioning, send a staff member to the switchboard to assist as messenger. D. If a fire occurs on 3rd floor during departmental hours, one person will take a fire extinguisher and report to the scene of the fire.

14 Montgomery Memorial Hospital Policy and Procedure Page 14 of 26 LABORATORY A. RACE B. Close all doors and file drawers. C. Turn off all electrical equipment, lights, gas, etc. FIRE OCCURS IN ANOTHER AREA OF HOSPITAL: A. Remain in (or report to) your own department. B. Close all doors/windows and secure area. C. On second shift, one person from the Lab is to respond to all fires with a fire extinguisher.

15 Montgomery Memorial Hospital Policy and Procedure Page 15 of 26 NURSING UNITS In the event that Security needs to leave the building, they should check out with the ED Charge Nurse and Switchboard. When Security is out of the building the Switchboard will need to call the Facilities Staff member on call when needed. A. Rescue, Alarm, Contain, Extinguish/Evacuate B. Follow instructions in general Fire Plan. C. Turn on lights in hallway at night. D. Use wet blankets under door of room where fire occurs. E. Removal of patients, when authorized to do so, is as follows: 1. Patients in immediate area of fire 2. Ambulatory patients and visitors 3. Wheelchair patients 4. Non-ambulatory/helpless patients Move patients through smoke barrier doors or exit farthest from the fire. F. Move any emergency equipment needed along with patient to evacuated area. G. If there is time and conditions permit, charts should be kept with the patients. INSTRUCTIONS FOR CHIEF NURSING OFFICER OR UNIT SUPERVISOR: A. Report to the scene of the fire. B. See that instructions in basic Fire Plan are carried out. C. Supervise removal of patients. The unit supervisor in each department is responsible for the safe removal of all patients in their care. D. Maintain a list of patients and see that all are accounted for. E. Charts should be sent with evacuated patients if there is time and conditions permit. F. In conjunction with Cardiopulmonary, consult Identification Map located on each unit and close central oxygen valve and any central gas in the area.

16 Montgomery Memorial Hospital Policy and Procedure Page 16 of 26 G. Assign a staff member to remain at the telephone to relay instructions and to be responsible for printing a patient census in case of evacuation. I INSTRUCTIONS FOR STAFF: A. Follow instructions in basic Fire Plan. B. Remain in halls outside assigned patient rooms; if patients are aware that there is a fire/potential fire, reassure them that alarms have been activated and that the hospital s emergency plan is in effect. C. Ask visitors to remain in patient s rooms until fire alert is over; visitors in the hallway may be asked to wait in waiting areas (as appropriate) on the floor. D. If evacuation is ordered, care should be taken to see that all patients are accounted for. IV. FIRE OCCURS IN ANOTHER AREA OF HOSPITAL A. Remain in, or report to, your assigned unit. Secure your area and await instructions. B. Prepare to carry out emergency procedures.

17 Montgomery Memorial Hospital Policy and Procedure Page 17 of 26 OPERATING ROOM & ANESTHESIA SERVICES A. Rescue, Alarm, Contain, Extinguish B. Follow instructions in general Fire Plan. C. Move patients in immediate danger. Keep list of patients to see that all are accounted for. D. Prepare any emergency equipment, which may need to be taken with patient(s). E. Notify surgeon immediately. F. Remove the drapes/burning material and douse any small fire with water from the back table. G. Care for the patient. H. Lower the inspired oxygen concentration as appropriate and consistent with anesthesia care of the patient and discontinue nitrous oxide if practicable. At the direction of the anesthesia provider the circulator will close the oxygen and nitrous oxide shutoff to the OR Room. I. Extinguish any remaining fire with the fire extinguisher. MANAGEMENT OF AIRWAY FIRE: A. Extinguish the fire. B. Immediately disconnect the patient from the anesthesia machine, switch off the anesthetic gas flow, ventilate with room air with a self-inflating ventilating bag, which is kept on the back of the anesthesia supply cart. C. Consider flushing saline down the endotracheal tube to extinguish any intraluminal fire. D. Consider removing or changing the tube to minimize the inhalation of toxic products of combustion. However, changing the tube may be more risky than leaving it in the patient if the patient was previously difficult to intubate or the airway has become edematous. If tube removal is deemed necessary consider using a ventilating exchange bougie. I EVACUATION: A. The decision to evacuate the OR will be made by the primary surgeon in that room. Notify ED and Cardiopulmonary of impending patient arrival. Cover any incisions with sterile towels. Patient transferred by CRNA who will manage airway. The safe evacuation area is to the ED.

18 Montgomery Memorial Hospital Policy and Procedure Page 18 of 26 IV. AFTERMATH: A. Document objectively, stating the events surrounding the fire. B. Do not discard any equipment involved in the incident, i.e. bovie pencil, ESU unit, laser, E.T. tube, drapes, etc. Sequester these items, notify OR management, Risk Management, and Biomed. V. FIRE OCCURS IN ANOTHER AREA OF HOSPITAL: A. Continue surgical procedures. B. Be prepared to carry out emergency procedures.

19 Montgomery Memorial Hospital Policy and Procedure Page 19 of 26 PHARMACY A. Rescue, Alarm, Contain, Extinguish B. Remove perpetual inventory of controlled substances to a safe place if possible. C. Close all file drawers. D. Following instructions in general fire plan. FIRE OCCURS IN ANOTHER AREA OF HOSPITAL: A. Close doors. B. Turn off all electrical equipment. C. If it becomes obvious that the switchboard, telephone and/or intercom system is not functioning, send a staff member to the switchboard to assist as messenger.

20 Montgomery Memorial Hospital Policy and Procedure Page 20 of 26 PHYSICAL THERAPY / REHAB SERVICES A. Rescue, Alarm, Contain, Extinguish B. Follow instructions in general Fire Plan. C. Turn of all appliances. D. Remove patient records. FIRE OCCURS IN ANOTHER AREA OF HOSPITAL: A. Close all doors/windows. B. Turn off all electrical equipment. C. Await further instructions. Available staff may be asked to assist with patient/resident evacuation or relocation should this become necessary.

21 Montgomery Memorial Hospital Policy and Procedure Page 21 of 26 PURCHASING DEPARTMENT A. Rescue, Alarm, Contain, Extinguish B. Follow instructions in general Fire Plan. FIRE OCCURS IN ANOTHER AREA OF THE HOSPITAL: A. Close all doors/windows. B. Turn of any electrical equipment. C. If it becomes obvious that the switchboard, telephone and/or intercom system is not functioning, send a staff member to the switchboard to assist as messenger.

22 Montgomery Memorial Hospital Policy and Procedure Page 22 of 26 QUALITY A. Rescue, Alarm, Contain, Extinguish B. Close all doors and file drawers. C. Turn off all electrical equipment, lights, etc. FIRE OCCURS IN ANOTHER AREA OF HOSPITAL: A. Turn off all electrical equipment. B. Close all doors and file drawers. C. Assist as needed throughout the facility. D. If it becomes obvious that the switchboard, telephone and/or intercom system is not functioning, send a staff member to the switchboard to assist as messenger.

23 Montgomery Memorial Hospital Policy and Procedure Page 23 of 26 RADIOLOGY / IMAGING SERVICES A. Rescue, Alarm, Contain, Extinguish B. Secure area and follow instructions in general Fire Plan. C. Close all doors. D. Turn off all electrical equipment. E. In conjunction with Cardiopulmonary, turn off all oxygen and remove mobile oxygen tanks. FIRE OCCURS IN NUCLEAR MEDICINE OR MRI MOBILE UNIT: A. Rescue, Alarm, Contain, Extinguish B. Call hospital operator to page Code Red in Nuclear Medicine/MRI mobile unit. C. Any available staff should respond. D. Staff are to access Nuclear Medicine/MRI fire extinguisher located by sliding glass door at ED nurses station. I FIRE OCCURS IN ANOTHER AREA OF THE HOSPITAL: A. Remain in, or report to, your own department. B. Close all doors. C. Secure area. D. On 2 nd shift, Radiology personnel are to respond to all fires with fire extinguisher.

24 Montgomery Memorial Hospital Policy and Procedure Page 24 of 26 REGISTRATION A. RACE B. Close all doors and file drawers. C. Turn off all electrical equipment. D. Keep track of file containing names and accounts of all patients in the hospital (census list) at the time of the fire (as a check against the switchboard file). E. If fire or water threatens office and it becomes apparent that evacuation may be ordered, gather all census reports, cash and valuables. Do not evacuate the area unless authorized to do so. Wait for instructions from Administrations or authorities. F. NOTE:Only CO2 fire extinguishers are to be used for computer fires. FIRE OCCURS IN ANOTHER AREA OF THE HOSPITAL: A. Carry out above instructions as authorized. Remain in your area to assist as needed and await further instructions from your supervisor or Administration. B. If switchboard is not working, staff will be assigned as messengers. C. If fire alarm is activated after normal switchboard hours, ED Registration staff will assume duties of switchboard. See Switchboard Department.

25 Montgomery Memorial Hospital Policy and Procedure Page 25 of 26 SECURITY GUARDS In the event that Security needs to leave the building, they should check out with the ED Charge Nurse and Switchboard. When Security is out of the building the Switchboard will need to call the Facilities Staff member on call when needed. Security Guards will be notified by Switchboard Operator of alarm/alert (in the event the Security Guard is not in-house). The Security Guard will be expected to assist all departments if there is a fire in or near the hospital. I. GENERAL GUIDELINES: A. Know the location and number of all fire alarm stations in the building. B. Know the location of all fire extinguishers. C. Know how and what type of fire extinguisher to use on each type of fire. D. Know location of all exits. E. Know location of all electrical switch panels on floors. IN THE EVENT OF A FIRE: Security Guard will go the Emergency Department entrance and wait for the fire department to assist with directions to the location of the fire. Unless there is a patient (or patients) in immediate danger, the Security Guard will not concern himself with the moving of patients until a safety check of the area has been made. I GUIDE FOR SAFETY CHECK IN THE EVENT OF A FIRE: A. Check enunciator panel at switchboard for location of fire. B. See that stairs and corridors are clear for passage; this is especially important if fire department responds to the scene.

26 Montgomery Memorial Hospital Policy and Procedure Page 26 of 26 SWITCHBOARD In the event that Security needs to leave the building, they should check out with the ED Charge Nurse and Switchboard. When Security is out of the building the Switchboard will need to call the Facilities Staff member on call when needed. I. Remain at the switchboard if the fire is not in the immediate area. The switchboard will serve the important function of control center. KEEP CALM! Keep lines open to department or area where fire is located. Receive calls from floors. Use discretion on outside calls. I Refer also the information outlined in the Fire Plan (pp. 1-6). IV. IN THE EVENT OF A FIRE: A. The facility s fire alarm system is automatically activated by smoke and heat and manually by pull station. B. When the system is activated, digital displays (located at ED Switchboard Office, Acute Care Nurses Station, Maintenance Department, and Data Support Office) will show the location of the smoke detector activated or the area of the pull-station activated. C. When this occurs, the Switchboard Operator (Registration staff after hours) will broadcast the following message over the paging system and notify Security. CODE RED --Followed by message on display (which is location of fire/potential fire) This announcement will be repeated three (3) times. After an approximate 15 second pause, the message will be repeated two (2) additional times. D. The alarm system automatically (through a monitor control system) notifies the local fire department. It should not be necessary to call 911. E. Notify the following persons (if not in-house): Security Facility Services personnel on-call Administrator/Administrative staff member on-call F. If the intercom system is not functioning, notification of the alarm is to be made by messenger. Departments not providing direct patient care are to send staff members to the switchboard to assist as messengers if it becomes obvious that the switchboard, telephone and/or intercom systems are not functioning. G. Upon notification by person(s) in charge (Facilities, Security, Administrator/Administrative Staff member on-call or Unit Supervisor) that the fire has been contained, the operator is to announce the following message three (3) times over the intercom system: CODE RED IS CLEAR Reviewed: 7/91, 6/94, 8/09, 3/10, 5/10, 6/10, 1/11, 1/12 Revised: 5/97, 11/99, 2/01, 4/02, 9/03, 11/04, 12/05, 1/07, 8/08, 8/09, 3/10, 5/10, 6/10, 1/11, 1/12 C:\Users\ctaylor\AppData\Local\Temp\Code Red - Fire Emergency Plan-1.odt