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Frequently Asked Questions
For Emergencies & Fire Drills in Healthcare Buildings

Healthcare Buildings Fire Drills
Healthcare Buildings Fire Emergency
Academic/Research Buildings Fire Drills
Academic/Research Buildings Fire Emergency

In an effort to improve safety at UTMB and to meet Joint Commission on Accreditation for Healthcare Organizations (JCAHO) requirements, UTMB conducts periodic fire drills. These drills are designed to simulate actual fire emergencies and to help train staff in their responses

to these emergencies. These drills are conducted according to JCAHO requirements for fire drills which require that drills be conducted once per shift per quarter per building. However, Joint Commission allows "properly documented actual or false alarms to be used for 50 % of required drills for each shift, if all elements of the fire plan were implemented." A further JCAHO requirement is that all personnel of all shifts in all areas of every building participate in drills.

Key to appropriate responses during fire drills and fire emergencies is the R.A.C.E. concept. The R.A.C.E. concept is based on an acronym made from the first letter of each step to be followed during a fire drill or fire emergency. The steps, which are followed in order, are:

R - Rescue. Move those in immediate danger to an area of safety
A - Alarm. Sound the alarm by calling 21211 AND activating the nearest pull station
C - Contain. Close all doors in your area to slow the spread of fire and smoke
E - Extinguish or evacuate. You should only attempt to extinguish a fire if you have had appropriate training

Important Note
It is important to note that there are only two significant differences between a fire emergency and a fire drill. The first difference is that staff immediately involved in direct patient care are excused from participating in the fire drill. The second difference is "actual patient transfer or transport and building evacuation are not required." Business occupants in a healthcare building however, are to perform exit drills which require that at "least one staff member continues to and through the exit from the building to ensure exits are well lit and unobstructed."

 

FIRE DRILLS - Healthcare Buildings

Q. Why do we have fire drills?
A. To ensure the safety of our patients, visitors, students and staff. We also conduct fire drills to meet Joint Commission requirements for health care facilities.

Q. Who is involved in a fire drill?
A. All UTMB employees and students in the building are required to participate in fire drills. Staff involved in direct patient care are excused from fire drills and business occupants of a healthcare building are required to participated by sending at least one staff member to and through the exit of the building to ensure exits are well lit and unobstructed.

Q. If the alarm is announced, by overhead page, for a floor other than the one I am on, am I involved?
A. Yes. All fire alarms involve all of the occupants of the building regardless of the floor that they are on.

Q. When should we fill out a Fire Alarm Response Report?
A. Please fill out a Fire Alarm Response Report whenever a drill is conducted in your building. The reports are a mechanism for assessing life safety needs, fire safety and JCAHO compliance. JCAHO allows 50 % of drills to be replaced by appropriately documented actual fire incidents.

Q. Do we have to turn in Fire Alarm Response Reports when we hear a "Dr. Red Fire Drill" page from another building or an alarm in an adjoining building?
A. No, reports only need to be submitted if the alarm is in your building. However, if you aren't sure, please go ahead and submit a report.

Q. If we hear the fire alarm going off in our building, do we call 21211?
A. No, the only time that you should call, ext. 21211 is when the fire drill originates in your area. The fire phone telephone number (21211) is NOT for inquires.

Q. Are personnel from adjacent areas expected to go to the alarm area?
A. No, personnel from areas adjoining the fire drill alarm area should NOT respond to those areas.

Q. If I am in the lobby of a building when the alarm goes off, what should I do?
A. If you are in the lobby of a building when the alarm goes off, please exit the building. If you open a door and the alarm is sounding in that building, please do not enter.

Q. Why do we have so many fire alarms in health care areas during the day time hours?
A. Because the NFPA requires to checks of all audible and visual fire alarm devices, building fire pumps and emergency generators and because of actual fire incidents.

Q. How many compliant drills does JCAHO require?
A. One compliant drill per shift per healthcare building per quarter.

Q. What is required for a drill to be compliant?
A. It should be noted that smoke compartments do not always correlate with units, areas, or departments. Joint Commission requires documentation from the alarm area, the adjacent smoke compartment (if applicable), the smoke compartment above OR below (if applicable) and from an additional 20 % of the remaining occupied smoke compartments.

Q. I work in a direct patient care area, what do I do if when there is a fire drill in my building?
A. If the drill originates in your area, you are expected to:

  • Determine the location of the fire.
  • Rescue those in immediate danger.
  • Activate the alarm by:
    1. calling ext. 21211, AND
    2. activating a manual fire alarm pull station
  • Close all doors.
  • Clear corridors.
  • Attempt to extinguish the fire, if properly trained.
  • Follow any special departmental procedures.
  • Document the event by completing the Fire Alarm Response Report and fax it to Occupational Safety and Fire Prevention at 70517.

    In the University Health Clinics, McCullough Building, Clinical Sciences, Primary Care Pavilion, Children's, Rebecca Sealy, Jennie Sealy, or any clinics, one staff member from each area will complete the evacuation procedure by leaving the building and proceeding to and through the nearest exit.

    In John Sealy Annex, John Sealy Towers, Jennie Sealy Hospital, TDCJ Hospital, Waverly Smith Pavilion, or Emergency Room/Trauma Center, staff will defend / remain in place. This type of area is also expected to send all visitors to adjacent areas. Care should be taken to ensure that visitors are not left in waiting areas.
If the drill does NOT originate in your area, you are expected to:
  • Close all doors.
  • Clear corridors.
  • Maintain a state of heightened awareness.
  • Follow any special departmental procedures.
  • Document the event by completing the Fire Alarm Response Report and fax it to Occupational Safety and Fire Prevention at 70517.

    In the University Health Clinics, McCullough Building, Clinical Sciences, Primary Care Pavilion, or any clinics, one staff member from each area will complete the evacuation procedure by leaving the building by proceeding to and through the nearest exit.

    In John Sealy Annex, John Sealy Towers, Jennie Sealy Hospital, Children's Hospital, Rebecca Sealy Hospital, TDCJ Hospital, Waverly Smith Pavilion, or Emergency Room/Trauma Center, staff will defend / remain in place. This type of area is also expected to bring all visitors in adjacent areas into their area. Care should be taken to ensure that visitors are not left in waiting areas.
Q. I work in an office (or other non-patient care area) in a healthcare building, what do I do during a fire drill?
A. If the drill originates in your area, you are expected to:
  • Determine the location of the fire.
  • Rescue those in immediate danger.
  • Activate the alarm by:
    1. calling ext. 21211, AND
    2. activating a manual fire alarm pull station
  • Close all doors.
  • Follow any special departmental procedures.
  • One staff member from each area will complete the evacuation procedure by proceeding to and through the nearest exit
  • Document the event by completing the Fire Alarm Response Report and fax it to Occupational Safety and Fire Prevention at 70517
If the drill does NOT originate in you area, you are expected to:
  • Close all doors.
  • Follow any special departmental procedures.
  • One staff member from each area will complete the evacuation procedure by proceeding to and through the nearest exit
  • Document the event by completing the Fire Alarm Response Report and fax it to Occupational Safety and Fire Prevention at 70517

Q. Can I return to the building when the alarms stop ringing?
A. No, please wait to be informed of the "all clear" before returning to your area. The "all clear" will be given by a uniformed UTMB police officer, UTMB's Duty Fire Marshall or an overhead page.

 

FIRE EMERGENCIES - Healthcare Buildings

Q. Who is involved in a fire emergency?
A. All UTMB employees and students in the building are involved in fire emergencies.

Q. The alarm is announced, by overhead page, for a floor other than the one I am on, am I involved?
A. Yes, all fire alarms involve all of the occupants of the building regardless of the floor that they are on

Q. When should we fill out a Fire Alarm Response Report?
A. Please fill out the Fire Alarm Response Report whenever the alarm sounds in your area/building. The reports are a mechanism for assessing life safety needs, fire safety and JCAHO compliance. JCAHO allows 50 % of drills to be replaced by appropriately documented actual fire incidents.

Q. Do we have to turn in Fire Alarm Response Reports when we hear a "Dr. Red" page from another building or an alarm in an adjoining building?
A. No, reports only need to be submitted if the alarm is in your building. However, if you aren't sure, please go ahead and submit a report.

Q. If we hear the fire alarm going off in our building, do we call 21211?
A. No, the only time that you should call, ext. 21211 is when the fire emergency (fire, smoke, smell of smoke) originates in your area. The fire phone telephone number (21211) is NOT for inquires.

Q. Are personnel from adjacent areas expected to go to the alarm area?
A. No, personnel from areas adjoining the area where the fire originates should NOT respond to those areas.

Q. If I am in the lobby of a building when the alarm goes off, what should I do?
A. If you are in the lobby of a building when the alarm goes off, please exit the building. If you open a door and the alarm is sounding in that building, please do not enter.

Q. I work in a direct patient care area, what do I do if when there is a fire emergency in my building?
A. If the alarm originates in your area, you are expected to:

  • Determine the location of the fire.
  • Rescue those in immediate danger.
  • Activate the alarm by:
    1. calling ext. 21211, AND
    2. activating a manual fire alarm pull station
  • Close all doors.
  • Clear corridors.
  • Attempt to extinguish the fire, if properly trained.
  • Follow any special departmental procedures.
  • Document the event by completing the Fire Alarm Response Report and fax it to Occupational Safety and Fire Prevention at 70517

    In the University Health Clinics, McCullough Building, Clinical Sciences, Primary Care Pavilion, Rebecca Sealy Hospital, Jennie Sealy Hospital,Children's Hospital, or any clinics, everyone will evacuate by the nearest exit.

    In John Sealy Annex, John Sealy Towers, TDCJ Hospital, Waverly Smith Pavilion, or Emergency Room/Trauma Center, staff will defend / remain in place. The decision to evacuate will be made by the charge nurse and/or the Fire Chief from Galveston's Fire Department. This type of area is also expected to send all visitors to adjacent areas. Care should be taken to ensure that visitors are not left in waiting areas.
If the alarm does NOT originate in your area, you are expected to:
  • Close all doors.
  • Clear corridors.
  • Maintain a state of heightened awareness.
  • Follow any special departmental procedures.
  • Document the event by completing the Fire Alarm Response Report and fax it to Occupational Safety and Fire Prevention at 70517.

    In the University Health Clinics, McCullough Building, Clinical Sciences, Primary Care Pavilion, Rebecca Sealy Hospital, Jennie Sealy Hospital,Children's Hospital, or any clinics, everyone will evacuate by the nearest exit.

    In John Sealy Annex, John Sealy Towers, TDCJ Hospital, Waverly Smith Pavilion, or Emergency Room/Trauma Center, staff will defend / remain in place. The decision to evacuate will be made by the charge nurse and/or the Fire Chief from Galveston's Fire Department. This type of area is also expected to send all visitors to adjacent areas. Care should be taken to ensure that visitors are not left in waiting areas.

Q. I work in an office (or other non-patient care area) in a healthcare building, what do I do during a fire emergency?
A. If the alarm originates in your area, you are expected to:

  • Determine the location of the fire.
  • Rescue those in immediate danger.
  • Activate the alarm by:
    1. calling ext. 21211, AND
    2. activating a manual fire alarm pull station
  • Close all doors.
  • Follow any special departmental procedures.
  • Evacuate the building and go to your area's rally point.
  • Document the event by completing the Fire Alarm Response Report and fax it to Occupational Safety and Fire Prevention at 70517
If the alarm does NOT originate in you area, you are expected to:
  • Close all doors.
  • Follow any special departmental procedures.
  • Evacuate the building and go to your area's rally point.
  • Document the event by completing the Fire Alarm Response Report and fax it to Occupational Safety and Fire Prevention at 70517

Q. Can I return to the building when the alarms stop ringing?
A. No, please wait to be informed of the "all clear" before returning to your area. The "all clear" will be given by a uniformed UTMB police officer, UTMB's Duty Fire Marshall or an overhead page.

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