UTMB HANDBOOK OF OPERATING PROCEDURES

Section 8 Health and Safety Subject 8.1 Preventive, Occupational and Environmental Medicine Policy 8.1.5 Fire Alarm and Incident Response Policy

12/01/97 -Originated 07/16/06 -Reviewed w/ changes -Reviewed w/out changes Environmental Health and Safety -Author

Fire Alarm and Incident Response Policy

Policy

UTMB is committed to creating and maintaining an environment that is safe. To that end, all employees, contract workers, students, patients and volunteers are required to participate in fire safety practices. This policy is designed to improve fire safety awareness at UTMB and meet the requirements set forth by the Joint Commission on Accreditation for Healthcare Organizations (JCAHO); it clearly defines the required procedures for Fire Alarm and Incident Response in all buildings owned or leased by UTMB.

Definitions

ALL CLEAR: A signal that indicates that the incident has been resolved and departments may return to normal operations. The signal may be given by: Environmental Health and Service – Occupational Safety and Fire Prevention (EHS-OS&FP), UTMB Campus Police or the Galveston Fire Department (GFD). FIRE ALARM: Any Fire Alarm System activation to which all personnel respond. This may include fire drills, system malfunction, system maintenance/testing or accidental activation. FIRE DRILL: Any scheduled fire alarm activation to practice the appropriate response to a fire alarm, including any other scheduled activation of the fire alarm system as approved by Environmental Health and Service – Occupational Safety and Fire Prevention (EHS-OS&FP). FIRE INCIDENT: Any unscheduled activation of the Fire Alarm System upon detection of smoke, fire, and smell of gas, electrical fire, or other burning odors. HEALTHCARE OCCUPANCIES: Those used for purposes such as medical or other treatment and care of persons of all ages suffering from physical or mental illness, disease, infirmity or convalescents. IN-PATIENT HEALTHCARE: occupancies that provide sleeping facilities and are occupied by persons who are mostly incapable of self preservation due to age, physical or mental disability, or due to security measures not under the control of the occupants. In-Patient Healthcare occupancies are located in John Sealy Annex, John Sealy

Definitions, continued

Hospital, TDCJ Hospital, Waverly Smith Pavilion, Children’s Hospital, Trauma Center, and Rebecca Sealy Hospital. OUTPATIENT HEALTHCARE: occupancies which provide services with no sleeping facilities and are occupied by persons who are mostly capable of self-preservation. Out-Patient Healthcare occupancies are located in McCullough Building, Clinical Sciences Building, University Hospital Clinics Building, Primary Care Pavilion and all other clinics. ANCILLARY HEALTHCARE: An area in a healthcare building not used for the direct care of patients. Examples include Administrative offices, Barber shops, Cafeterias, Coffee shops, Chapels and Gift shops. NON-HEALTHCARE OCCUPANCY: Buildings used for activities other than patient care. This includes, but is not limited to research, business, administration, warehouse and industrial. SPECIALIZED AREAS: An area that operates under unique conditions due to the contents of or processes performed there. These areas shall be so designated by EHS-OS&FP.

Roles and Responsibilities

Alarm Area Leaders – A person assigned to be responsible for an area during a Fire Alarm. In healthcare areas, the Alarm Area Leader will generally be the unit charge nurse. In non-healthcare areas, the Alarm Area Leader may include supervisors or area administrators. Any one department may have multiple Alarm Area Leaders. The responsibilities of the Alarm Area Leader include: • Knowledge of the primary and secondary evacuation routes for the area • Ensuring that all personnel are accounted for and notifying responders if personnel may remain in the building. • Ensuring that all personnel receive the “all clear” before returning to the building • Completing the Fire Alarm Response Report Area Supervisor – Area supervisors are responsible for ensuring the appropriate fire alarm response occurs during all incidents.

Roles and Responsibilities, continued

Department Heads – Department heads shall ensure that all new employees attend the mandatory fire safety training as scheduled and required by Human Resources. Department heads are also responsible for area-specific training and written fire alarm response policies. Designation of specialized roles for the area, (i.e. Alarm Area Leaders) Employees – Every employee shall respond to all fire alarms in an appropriate manner and shall know their individual role and responsibility in such occurrences. During fire alarms, employees should know: • the RACE concept and its appropriate use • the fire phone telephone number • the location and operation of a manual fire alarm pull station • to report to the Alarm Area Leader for direction If an employee is in a work area outside of their department during a fire alarm, he/she should report to the Alarm Area Leader for that area for assignments.

Fire Alarm Response

Upon activation of the Fire Alarm, occupants shall: Ancillary Patient Care Areas: • Close all doors and clear hallways and corridors of all obstructions that may include but are not limited to chairs, boxes, carts and beds • Follow any special department procedures • Evacuate the building • Proceed to the rally point for your area and check in with the Alarm Area Leader • Return to normal operations after and all clear has been given Healthcare Occupancies (in-patient and out-patient): • Close all doors and clear corridors • Report to the Alarm Area Leader for further directions • Maintain a state of heightened awareness • Follow any special department procedures

Fire Alarm Response, continued

• Return to normal operations after an all clear has been given Non-healthcare Occupancies • Close all doors • Follow any departmental specific procedures • Evacuate the building • Proceed to the rally point for your area and check in with the Alarm Area Leader or their designee Specialized Areas: • Alarm Area Leader implements their department specific response plan as appropriate • Return to normal operations after an all clear has been given

Fire Incident Response

Fire Incident Response: Any occupant of a building owned or leased by UTMB shall follow the RACE concept upon discovery or evidence of a fire. Healthcare Occupancies (in-patient and out-patient): • Determine the location of the fire or smoke • Alarm Area Leader activates RACE • Close all doors and clear all corridors • Follow any departmental specific procedures • Inform patients and visitors of incident status • Prepare for a possible evacuation • Return to normal operations after an all clear has been given Ancillary Patient Care Areas and Non-healthcare Occupancies: • Determine the location of the fire or smoke • Alarm Area Leader activates RACE • Communicate incident status to personnel in the immediate and immediately adjacent areas • Follow any departmental specific procedures • Evacuate the building, proceed to the rally point for your area and check in with the Alarm Area Leader or their designee Return to normal operations after an all clear has been given. Specialized Areas:

Fire Incident Response, continued	• Determine the location of the fire or smoke • Alarm Area Leader activates the RACE concept • Communicate incident status to personnel in the immediate and immediately adjacent areas • Area implements their department specific response plan as appropriate • Return to normal operations after an all clear has been given
Evacuation	Healthcare Occupancies and Specialized Areas: Evacuation is appropriate in two situations: • Imminent Danger Evacuation: An evacuation performed to remove a person from the immediate source of danger. • Precautionary Evacuation: An evacuation performed to expand the safe zone around an existing source of danger (i.e., a fire on the floor below). • Hospital administration will order evacuations of healthcare occupancies. A specialty area representative will order evacuations of specialty areas. Evacuations shall be ordered upon the mandate of the representatives from the Galveston Fire Department, UTMB Environmental health and Safety Department, or UTMB Police Department. Non-Healthcare Occupancies: Evacuation of the building shall occur for each incident. If any departmental specific procedures exist, evacuation shall occur immediately following the completion of said procedures. In all situations, follow all departmental-specific procedures.
Fire Incident Reporting	Standard Incident Reporting Procedures: At the time of the fire incident, the appropriate Fire Alarm Response Report will be completed by: • the Alarm Area Leader • the responding officer of the UTMB Police Department • the responding personnel for FOAM Maintenance • the responding representative of EHS-OS&FP

Fire Incident Reporting, continued	During regular working hours: Reports from all responding parties shall be sent to UTMB Police Dispatch. After hours, weekends , or holidays: • FOAM Maintenance representative: leave the report at the Control Office of FOAM-Utilities Plant. • UTMB Police representative: leave the report at the UTMB Police Department administrative offices. • Alarm Area Leader: forward the original report to EHS-OS&FP. EHS-OS&FP representative shall collect all written reports at the beginning of the next business day. EHS-OS&FP will forward a copy of the Alarm Area Leader’s written report to the area’s department head. Additional Incident Reporting Procedures: EHS-OS&FP will generate a written report within 8 working hours of a fire emergency if one of the following conditions occurs: • a death • an injury • damage over $1,000 Copies of this report will be sent to the: • leader of EHS-OS&FP • UTMB Institutional Safety Officer • chief of the UTMB Police Department • chair of the General Safety Committee • department head of the incident area If the incident occurs in a healthcare occupancy, a copy of the report will also be sent to the: • Medical Director of Inpatient Care • Hospital Executive Director • Hospital Administrator • Chair of the Environment of Care Committee • Chair of the Life Safety Committee
Department Specific Procedures	All departments are required to have a Department Specific response plan for each separate area on file (electronic or hard copy) with EHS Occupation Safety and Fire Prevention. The Department Head is responsible for creating the plan. The following requirements apply: • A copy of the plan shall be kept in an area that is easily accessible by the staff • Staff (new and existing) shall have additional training as required. • Plans shall be updated a minimum of once a year or when a department/area relocates. • Each September EHS Occupational Safety and Fire Prevention shall be provided with a copy of the updated plans or notified that the existing plans are acceptable. Note: Assistance in writing policies is available through Environmental Health and Safety – Occupational Safety and Fire Prevention (EHS-OS&FP).
References	• The National Fire Protection Association (NFPA) • Joint Commission on Accreditation of Healthcare Organizations (JCAHO) • UTMB Emergency Preparedness Plan