HCPC Fire Plan

Introduction

Date of Last Review 11/30/07
SME: Safety Compliance Coordinator

This topic introduces UTHCPC fire emergency general preparation.

Purpose:
The UTHCPC Fire Plan is designed to ensure all personnel are familiar with life safety measures. This plan ensures safe and effective actions in the event of a fire and provides information regarding the use and function of fire alarm systems; the containment of fire and smoke, and partial emergency evacuation procedures.

RACE system

For a fire discovered prior to the alarm sounding use the "RACE" system as follows:

RACE	Description
Rescue	Move any patients/staff in immediate danger to a safe area
Activate	Trigger the alarm with the manual fire alarm pull station Call Security at extension 7223 (RACE) Alert immediate staff Implement departmental fire plan
Contain	Close all doors If possible, extinguish the fire
Evacuate	Evacuate the department in the following conditions: Patients/staff are unable to extinguish the fire Patients/staff receive orders to evacuate Evacuation procedure: Horizontal evacuation – Move occupants from one fire zone to another fire zone. Vertical evacuation – Move occupants from one fire zone to another fire zone located on the next lower level floor. If the next lower level floor is involved in the fire then evacuate to the next upper level floor. A head count of patients and staff must be done to confirm all occupants have been accounted for after the evacuation is complete.

Fire Alarm System

UTHCPC has smoke detectors located in strategic areas throughout UTHCPC that activate the alarm system when products of combustion are detected.

Components of the alarm system are as follows:

	The audible alarm is a loud sounding horn that is coded to indicate the floor and zone where the alarm was activated. Alarm series: The alarm series is as follows:
-	The first series of the alarm (1-4) identifies the level; first floor, second floor, third floor, and four tones identify the roof.
-	The second series of the alarm (1-8) identifies the zone on that floor
	The visual fire alarm is a blinking light inside of a white plastic sign (with the word "Fire" on it) Location: Mounted on the upper wall at various locations throughout the hospital

Fire Zone Floor Plan- First Floor Zone , Second Floor Zone , Third Floor Zone

Other automatic fire alarm/suppression systems are as follows:

	The telephone room is protected with Halon and the computer mainframe is protected with Inergen Fire System.
	Range and fryer vent hoods are equipped with automatic dry chemical fire suppression systems

Manual pull stations location/activation

Alarm pull station location:
UTHCPC has manual fire alarm pull stations located as follows:

	At each main elevator lobby
	On each level at all of the fire exit stairways
	Inside the stairways leading from patient care units
	Employee lounge
	Staff cafeteria
	Computer mainframe room

Alarm pull station activation:
To activate the alarm system from a manual pull station, pull down on the center bar marked Pull Down.

Alarm pull station handle:
The handle remains in the down position until Operations, Safety, or Security activates the release mechanism.

Alarm monitoring

Alarm system monitor location:
A master fire alarm system monitor and control panel is located in the operator's room (1A-59) on the first floor adjacent to the main lobby. A duplicate panel is located at the UT Police guard station.

Alarm system monitor use:
The alarm system monitor and the control panel indicate the location of any smoke detector, sprinkler head, or manual pull station that has been activated.

Portable emergency telephone headsets

Portable emergency telephone headsets (for use by fire department personnel only) are located in room’s 1A-59 and 1A-74.

Fire exits/stairwell locations

Fire exit stairwell locations are as follows:

On each patient care unit

At the main elevator lobbies

At the far ends of the East-West corridors

Exit signs

Each fire exit has a lighted ceiling mounted "EXIT" sign located above the exit.

Unlocking exit stairwells

Unlock the doors to fire exit stairwells as follows:

Stairways in the patient care units are locked and can be unlocked by the same key that unlocks all corridors to patient care units (A4-20)

Elevator lobby and East-West corridor fire exit stairway doors are not locked. Stairwell "C" exit to the loading dock is locked.

Ground level fire exit stairway doors leading to the outside can only be opened from the inside of the building

Fire extinguishers

Portable multi-purpose dry chemical fire extinguishers are located as follows:

In the Chart Rooms of each patient care unit

Throughout UTHCPC for use on the following types of fires:

Trash/wood/paper (Class A)

Flammable/liquids/grease (Class B)

Electrical equipment (Class C)

Portable CO₂ fire extinguishers:
Portable CO₂ fire extinguishers are located in the main kitchen cooking area for use on grease fires.

Elevator use during fire emergency

Elevator use is not allowed during a fire emergency. When the fire alarm system is activated, all the elevators stay on the first floor and remain stationary with the doors open. If the fire is on the first floor, the elevator stays on the second floor.

Individuals responding to alarm

The following individuals respond to the "Code Red" location and take appropriate action as the senior staff member present directs:

Staff response

Staff response for fire general emergency is as follows:

Alarm sounds/
location unknown

If a fire alarm sounds and the location of the fire is not known, staff proceeds as follows:

Stage	Staff Responsible	Description
1	Department staff	Close all doors Stand by for further instructions Implement department/unit fire plan
2	The senior staff member at the scene	Does s/he determine it is necessary to call the fire department? If yes, then notifies Security to call the fire department and the process continues to stage five Security extension: RACE (7223) If no, then notifies Security of false alarm, process stops
3	Security	Notify the U.T. Police dispatcher
4	U.T. Police dispatcher	Notifies the Houston Fire department

Department /unit plan

Each department, unit, and satellite facility submits a department/unit fire plan tailored to their individual requirements to the Safety Office for review.

Fire Alert Code
An internal fire alert shall be termed a Code Red

Safety office responsibilities

The Safety Office is responsible for the following:

	Administration and approval of the UTHCPC Fire Plan
	Making sure that the department/unit fire plans are an addendum to the UTHCPC Fire Plan

Inclusion

The department/unit fire plan structure must contain the following:

	A copy of the UTHCPC fire plan plus the specific requirements of the individual unit/department
	Location of fire extinguishers in the department
	Location of fire alarm pull boxes nearest to the department
	Location of adjacent safe zones
	Location of evacuation routes
	Duties of department staff by job title in the event of a fire emergency in their area Inclusion: Duties should include moving to an adjacent area and in case of evacuation
	Map of the area showing locations of fire extinguishers, fire alarm pull stations, adjacent safe area and evacuation routes

Department requiring plans

These departments/units require fire plans:

Department/Units
Support Services	Administration	Patient Registration
Food and Nutrition Services	Facilities Management	Volunteer Services
Nursing	Pharmacy	EEG/Lab
Public Information and Education	Social Services	Health Information Management

Administration notification

The Administrator on-call must be notified of actual fires in the following situations:

When individual injury occurs

When the Fire Department is notified during all shifts

Administrator on-call schedule: The published on-call schedule ascertains who is the appropriate Administrator on-call.

Safety Office notification

Staff must notify the Safety Office of all fires occurring at UTHCPC during all the shifts after establishing the patient's safety.

Documentation

The following documentation is required when a fire incident occurs at UTHCPC:

The senior staff member present completes an Occurrence Report

Related Standards

The Joint Commission : Environment of Care

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