North York General Hospital Policy Manual

of 6 POLICY STATEMENT North York General Hospital staff is responsible to follow the guidelines outlined in this document in the event of a fire to minimize injury and/or damage. DEFINITIONS Code Captain: The individual who is designated as being responsible for coordinating and assigning personnel to carry out procedures/instructions during a Code Red; this role would usually be assumed by the Charge Person until a more senior individual arrives. Code Red: A situation in which the fire alarm system has been triggered into alarm. This could be caused by various situations occurring: Person triggering the pull station Smoke triggering a detector Heat triggering a detector Sprinkler activation Code Red All Clear: Announced overhead when all areas are able to resume normal duties. Code Red In Effect: Announcement made by Telecommunications to alert staff that the facility remains in a code Red Alert. Announcement made overhead. All areas are required to: Implement their area specific Code Red procedures and the relevant contingency plans. Prepare for evacuation in the event Code Green is announced. Stages of Evacuation: Room - Removal from immediate area Horizontal - Removal of patients from one Unit (fire affected zone) to another Unit (fire safe zone) on the same floor. (Refer to CODE GREEN, AREA SPECIFIC) Vertical - Removal of patients from one Unit (fire affected zone) to another Unit (fire safe zone) on the floor below except in the

of 6 basement (should evac. upward). (Refer to CODE GREEN, AREA SPECIFIC) Outside - Removal of all patients from the building (Refer to CODE GREEN) Incident Commander: Person responsible for directing and coordinating all activities related to the incident. Upon the arrival of an individual with more expertise, this role may be transferred to him/her. ROLES & RESPONSIBILITIES OF STAFF MEMBER ENCOUNTERING A CODE RED R E A C T Remove those in immediate danger if possible and call out CODE RED, Location for assistance. Ensure doors are closed to confine fire and smoke. Activate the fire alarm using the nearest pull station. Call the switchboard (5555) to give exact location and nature of fire and call 911. Try to extinguish the fire or continue to evacuate if you are not confident in your ability to put out the fire promptly. ROLES & RESPONSIBILITIES OF TELECOMMUNICATIONS NYGH and Branson: Telecommunication operators Seniors Health Centre: Staff 1. Announce the Code Red status and affected area(s) on the designated pagers and the overhead paging system. ATTENTION! ATTENTION! CODE RED and LOCATION of fire alert, to be paged three (3) times at five second intervals. 2. Dial 9-911, specify PLEASE NOTIFY TORONTO FIRE SERVICES - NORTH COMMAND, indicate it is a Fire Alert and give the zone/location 3. Notify Security on two-way radios and pagers of location of Fire Alert 4. If fire confirmed or directed by Security, notify Unit Administrator on-call, Senior Administrator on-call, Life Safety Officer and Manager of Telecommunications and Protection Services 5. When directed by the Life Safety Officer, Security or Toronto Fire Department, announce ATTENTION! ATTENTION! CODE RED, ALL CLEAR PLEASE RESUME NORMAL DUTIES.

of 6 ROLES & RESPONSIBILITIES OF SECURITY All available Security Officers will: 1. Upon notification, immediately proceed to the fire area 2. Assume role of incident commander 3. Advise telecommunications of Fire Status 4. Instruct telecommunications to announce ALL CLEAR after receiving clearance from the Toronto Fire Services Incident Commander and/or Life Safety officer and/or security One Security Officer (at Branson shift Engineer) will: 1. Respond to West Entrance (main entrance at Branson) 2. Find location of fire from the Annunciator Panel and inform the Fire Department immediately when they arrive 3. Advise drivers in vehicles waiting to pick up patients to immediately move 4. Escort the Toronto Fire Services to the scene of the alarm. ROLES & RESPONSIBILITIES OF ENVIRONMENTAL SERVICES AND PORTERING 1. One staff member, from each department, report to the fire area (all shifts) 2. Fulfil duties as assigned by the Incident Commander ROLES & RESPONSIBILITIES OF BUILDING SERVICES. 1. Building Services staff assigned to the Fire Team will arrive at fire area once announced overhead 2. Engineer to reset Fire Alarm Panel and restore Hospital Ventilation System at the direction of the Toronto Fire Services chief and/or the incident commander FIRE EVACUATION PLAN Horizontal, Vertical or Total Evacuation may be required in the event of fire to relocate patients who are at risk from smoke, fire or noxious gases.

of 6 The Hospital has been designed and constructed so that each room is separated from other areas with walls and doors built of materials that will contain a fire for a least one hour. In addition, each floor is divided into fire zones which are separated from each other by fire walls and doors constructed of materials which will contain a fire for no less than one hour. The Hospital is also designed so that a 2 hour fire separation exists between each floor. In addition, the stairwells, elevators, dumbwaiters and all vertical openings and shafts are enclosed in fire restrictive enclosures to maintain this separation. Considering these built-in features and providing staff members act promptly to close doors, horizontal and vertical movements of patients from a fire affected zone to a fire safe zone may be achieved effectively and safely. FIRE ALARM First stage (initial) alarm is 20 strokes per minute. Second stage (evacuation) alarm is a steady ring (120 strokes per minute). When Evacuation Alarm sounds (second stage), prepare evacuation according to CODE GREEN STAT. ELEVATORS Do not use elevators unless directed by the Toronto Fire Service in conjunction with the person in charge ROOM EVACUATION Authority: Room evacuation should be initiated immediately by the first responder to the fire. Duties: Remove people in immediate danger and follow R.E.A.C.T procedures. HORIZONTAL EVACUATION (CODE GREEN, AREA SPECIFIC) Authority: Horizontal evacuation will be initiated on the order of the person in charge.

of 6 Duties: Remove people in immediate danger. Notify Communications of evacuation. The Code-Captain of the fire affected zone will be responsible for patient safety, security of patient records and the narcotic key and for ensuring that all patients and staff are accounted for. The Code-Captain of the Unit(s) adjacent to the fire affected Unit should be ready to receive patients and to assist the Code-Captain of the fire affected zone in recording location of patients. VERTICAL EVACUATION (CODE GREEN, AREA SPECIFIC) Vertical evacuation may be necessary where it is not practical to remove patients to another Unit on the same floor (e.g. the greatest danger may be at the entrance to the Unit). Authority: Vertical evacuation may be initiated on the order of the person in charge. Duties: If fire cannot be extinguished or contained, and before smoke is threatening and egress is not possible horizontally, begin vertical evacuation downward as follows: a) Remove people in immediate danger. b) Notify Communications c) Remove ambulatory patients (Under guidance of a staff member, ambulatory patients holding hands in single file can be taken down stairs to the floor below). d) Do not use elevators. e) Remove non-ambulatory patients. (Non-ambulatory patients are transported down the stairs using blankets for transport). The Code-Captain of the fire affected zone will be responsible for patient safety, security of patient records, the narcotic key and for ensuring that all patients are accounted for. The Code-Captain of the Unit(s) below the fire affected Unit should be ready to receive patients and to assist the Code- Captain of the fire affected zone in recording location of patients.

of 6 All Department/Patient Care Units are expected to have specific, predetermined horizontal and vertical evacuation plans. OUTSIDE EVACUATION OF HOSPITAL Please refer to Evacuation Procedures detailed in CODE GREEN STAT. POST EVENT DEBRIEFING Life Safety Officer meets with Security officers, telecommunications and fire team after ALL CLEAR has been sound. POST EVENT DOCUMENTATION: Person who initiated Code Red will complete SLIP electronically within 48 hours. If a patient/visitor is injured, a SLIP will be completed within 48 hours. An Employee Incident Form will be completed with 24 hours, if a staff member has been injured. Unit Administrator/ Manager must sign and submit the form to Occupational Health and Safety. Staff member must be seen in Occupational Health or in the Emergency Department, if employee requires treatment. North York General Hospital Fire Alarm Evaluation form must be completed within 24 hours by Life Safety Officer or designate. Forward to Corporate Risk Manager.