fire safety plan - fhs.mcmaster.ca
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Hamilton Health Science Fire Safety Plan –McMaster Children’s Hospital
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FIRE SAFETY PLAN FIRE – LIFE EMERGENCY – 5555
GENERAL ENQUIRES
MUMC SECURITY – 76444
SECURITY CONTROL CENTER 77753
MUMC ENGINEERING 75501
1200 King St W
Hamilton, Ontario
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Emergency Fire Safety and Evacuation
The Fire Emergency Plan - Instruction Guide has been compiled as the
predominant document to the HHS Code Red and Green Procedures.
This information is intended to provide detailed direction on procedures and
protocols to be followed in the event of a fire in the Hospital.
Staff must be familiar with this content as well as the Corporate Code
Red Procedure and their Area-Specific Code Red and Green
Procedures
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TABLE OF CONTENTS
General Inquiries.............................................................................................1
• Phone numbers for general inquiries
INTRODUCTION…………………………………………………………………….4
Purpose and Goal
RESOURCES of BUILDING …………………………………………….…………6
Description of Building
Occupants
Ownership
Escalation List
Life Safety Systems
Electrical, Utility & Fuel Supply
1.0 Fire Alarm ................................................................................................. 9
1.1 First Stage
1.1.1 First Stage Alarm H.E.A.T 1.2 Second Stage
2.0 Evacuation............................................................................................... 11
2.1 Preparation for an evacuation 2.2 Progressive Stages of Evacuation 2.3 Evacuation by Compartments 2.4 Horizontal Evacuation 2.5 Vertical Evacuation 2.6 Total Building Evacuation
3.0 ResponsibilitiesofStaff............................................................................13
3.1 Program, Service, Department Manager Responsibilities 3.2 Emergency Code Captain – Area Charge Person 3.3 Area Staff 3.4 Telecommunications
3.5 HHS Fire Response Team
3.6 Administration Responsibilities
4.0 Fire Response......................................................................................... 19
4.1 REACT, Smell of Smoke 4.1.1 First Stage Alarm for Staff, Patient, Visitors
4.1.2 Second Stage Alarm 4.2 Types of fires and extinguishers 4.3 Fire Hose 4.4 When to fight a fire
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5.0 Fire Safety for Occupants .......................................................................22
5.1 Staff Responsibility 5.2 Occupant/Staff training
6.0 Fire Hazard Control .................................................................................23
6.1 Building decorations 6.2 General/Personal Housekeeping
6.3 Storage, Handling and Use of Flammable Liquid
6.4 Open Flame Hazards Control
6.5 Unobstructed Access to Exits – Clear Corridors
6 .6 Electrical equipment and Appliances
6.6 Extension Cords
6.7 Portable electrical Heaters
7.0 Fire Safety Maintenance Regulations Ontario Fire Code………………………………….27
7.0 Engineering and Security Service’s - Fire Safety Maintenance Requirements
Appendix A – Code Green – Procedure for Evacuation ………………………………………....32 Appendix B – Use of voice communication building automation system and elevator ….…....43 Appendix C – 3G Child and Youth Mental Health Program………………………………….…...47
CAF (Central Animal Facility)
Appendix D- Code Brown / Hazardous spill control procedure……………………………….….49
Appendix E – Fire Site Plan ………………………………………………………………………...55
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Purpose and Goals This document must be kept available on the premises at all times for the use of supervisory
personnel; such personnel should be fully aware of their duties and responsibilities contained
herein.
The Fire Safety Plan (FSP) has been prepared to assist in the safe handling of a fire or smoke situation;
The fire procedure will assist all staff, visitors and patients in safe and effective response to a fire or smoke situation
Every member of HHS has a responsibility to maintain knowledge of the fire safety plan, supporting procedures and has a responsibility to participate in fire prevention.
The “Owner” is responsible to completely review the material contained herein and to ensure
that any errors or omissions are corrected. The on-going integrity of this Fire Safety Plan must
also be maintained in order to conform to the ONTARIO FIRE CODE and to ensure occupant
safety.
The Fire Protection and Prevention Act states that any person who contravenes any provision
of the Fire Code is guilty of an offence. Upon conviction, any company or corporation is liable to
a fine of not more than $500,000. Any individual, director or officer of a corporation is liable to
a fine of $50,000, a term of imprisonment of not more than one year, or both.
The Fire Department may require this Plan, or any part thereof, once approved, to be
resubmitted if any changes are made to the content, whether it be because there have been
changes to occupancy or use, or standards, or because the Chief Fire Official judges the current
Plan to be no longer acceptable. The Chief Fire Official is to be notified if any changes are made
to the Plan.
While it is reasonable to believe the Fire Department will assume command upon their arrival
at a fire emergency, it is nevertheless the responsibility of the owner(s) to ensure the safety of
the occupants at all times.
It is not necessary that the manager staff be in the building on a continuous basis, but they shall
have a delegate and be available on notification of a fire emergency, to fulfill their obligation(s)
as described in the Fire Safety Plan.
The absence of supervisory staff when a fire occurs could result in a failure to provide the
services required of supervisory staff pursuant to Section 2.8.2.2 of the Ontario Fire Code.
Supervisory staff shall be instructed in the fire emergency procedures as described in the Fire
Safety Plan before they are given any responsibility for fire safety.
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DESCRIPTION OF BUILDING
Building Information
Common Name McMaster Children’s Hospital (MUMC) Doc. File # (Fire Department use)
Address: 1200 King St. West
City: Hamilton Postal Code: L8S 4K1
Number of Stories: 4 Occupied Floors 7 Mechanical Floors 1 Underground Parking
Number of Beds: 120 Building Area: 1.2 M Sq. ft (occupied) 1.2 M Sq. ft (Mechanical/Parking)
Indicate which of the following activities take place in your building: Public Assembly Institutional (Hospital, Nursing/Group Home) Residential Office (includes medical offices) Mercantile/Retail Industrial
Indicate which of the above the major part of your building is. Hospital
Describe in your own words the business operations taking place in your building: Children’s Hospital/McMaster University classrooms and Labs
Building Facilities
Do you have a parking garage? Yes No
Do you have an elevator? Yes No
Is there a firefighter elevator? Yes No
Do you have smoke control devices? Yes No
Do you have pressurized stairwells? Yes No
Is there interior roof access? Yes No Where? Accessible from top of west stair
Do all stairwells exit to the exterior? Yes No If no explain?
Do you have hazardous materials stored on site? Yes No Location: Every department has a copy of the WHMIS binder as it applies to their specific area.
Building Access
Lock Box Chubb Location: Fire department access: Security will assist Knox Other Type
Entry Code
Onsite Building Information
Fire Safety Plan Revised Date: July 6,2020 Location:
WHMIS Information Location:
Other Location:
Occupants
Patients Approx... 200-300
Total
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Ownership
Building Owner: Hamilton Health Sciences Phone: Res: (905)521-2100 Cell: ( )
Address: 1200 King St West Bus:(905) Ext:
City: Hamilton Postal Code: : L8N 3Z5 Fax:( ) Pager:( )
Email:
Escalation List: ACTIVE CODE RED ONLY .
1.
Name: Director-on-Call Phone: Res: (905)521-2100 ext. 0 Cell:( )
Position: centralized resource Bus:(905) Ext:
Pager:( )
2.
Name: Facilities Manager on call Phone: Res: (905)521-2100 ext. 0 Cell:( )
Position: Engineering Bus:( 905) Ext:
Pager:( )
3.
Name: Phone: Res: ( ) Cell:( )
Position: Bus: (905)
Address: Fax: ( ) Pager:( )
Contractors – Service Company These are your contractors or fire alarm company personnel to be contacted in the event of problem requiring fire alarm or other maintenance at this building.
Name: Simplexgrinnell
Phone: Res: (905)577-4077 Cell:( )
Position: Fire Protection Contractor Bus:(905) Ext:
Address: 1-40 Hempstead Dr. Hamilton
Fax( ) Pager: )
Name: Protectron Phone: Res: (844)2304691 Cell:( )
Position: Monitoring Company Bus:1 (800) Ext:
Address: 8481 Langelier Blvd Montreal Qc Fax:( ) Pager:( )
Alarm Systems (If no fire alarm is present in the building, leave this blank and go to the Fire Protection Devices section.)
Main Fire Alarm Control Panel Location: Main entrance
Remote Annunciators Location(s): Switch Board, Ewart Angus Entrance, 6th Floor TS6,
Type of Alarm (Check the appropriate box below.)
Single Stage Two Stage Interconnected Smoke Detectors
Security/Intrusion Partial System Sprinkler System used as Fire Alarm
Fire Protection Devices (Check any that are present in your building)
Smoke Alarms (Battery or hardwire) Emergency Lighting (Generator)
Smoke Detectors (Alarm System) Carbon Monoxide Detectors
Heat Detectors Fire Extinguishers
Evacuation Communications System (PA) Communication (Phones)
Kitchen Hood Suppression System Other Magnetic hold opens for zone fire separations on each floor/wing. Magnetic locks will disengage upon activation of the fire alarm system.
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Water Supply
Is there a fire hydrant within 90 meters of your buildings front door? Yes No
Sprinkler System
Do you have a sprinkler system in your building? Yes No (If no, go to Standpipe Systems.)
If yes, does it cover your whole building? Yes No
If no, what areas are sprinklered? Every Area except Level 6
If you have a sprinkler system in your building, the following devices must be indicated on the diagram of your building: Fire Department Connection (Siamese) Connection, Sprinkler Control Room, Fire Pump(s), Main Control Valve, Isolation Control Valve(s), and Post Indicator Valve(s).
Is your sprinkler connected to the Fire Alarm? Yes No
If no, is there a water gong or other alerting device to indicate water flow? Yes No
Standpipe System
Do you have a standpipe system in your building? Yes No (If no, go to Fixed Extinguishing Systems.)
If yes, does it cover your whole building? Yes No
If no, what areas are covered?
Do your fire hose cabinets have fire extinguishers? Yes No
How are the hose cabinet doors opened if they are locked or fastened? Finger latch on door
If you have a standpipe system in your building, the following devices must be indicated on the diagram of your building: Fire Department Connection (Siamese) Connection, Hose Cabinets, and Main Shut Off Valve.
Fixed Extinguishing Systems Do you have one? Yes No (If no, go to Utility Provisions.)
Area Protected Type Specify Details
Kitchen (NFPA 96) 1T1 – Main Kitchen
Spray Booth
Other Communication Level MM - Halon System– Telephone Room
Extinguishing System connected to Fire Alarm Yes : No
Electrical, Utility & Fuel Supplies (check all that apply)
Water Main Shut off Main Electrical Shut off Refer to maps
Natural Gas Shut off Fuel Oil/Diesel Shut off Refer to maps
Emergency Generator Location:
Refuse
Sprinkler Coverage
Garbage Room Location: Yes
Garbage Chute Location: Yes
Garbage Compactor Location: Yes
Garbage Exterior Storage Location:
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1.0 Fire Alarm
The Fire Alarm is a TWO stage alarm
1.1 First stage
The fire alarm can be activated by smoke detectors, heat detectors, or flow measurement of water within the piping of the sprinkler system. This flow will only take place if a sprinkler head allows water to flow. Fire pull stations are activated manually.
The first stage alarm consists of slow sounding bells striking at 20 bells per minute. This is the ‘Fire Emergency Alert’. The slow sounding bells are meant to alert staff without alarming patients and visitors. The bells maybe silenced after approximately 3 minute. This automatic silencing of the bells does NOT signify an all clear.
Once the Fire Department is satisfied that the situation has been rectified, approval is given, and the all clear shall be announced. The All Clear is announced by Telecommunications using the overhead paging system announcing: “CODE RED - ALL CLEAR…Zone / Area / Dept.” IF YOU HEAR THE 1ST STAGE ALARM (intermittent bell) OR DISCOVER FIRE
1. Investigate zones for fire without putting yourself at risk. Quickly sweep the common areas, patient rooms and service rooms on your assigned floor for signs of fire. Notify the switchboard immediately at 'ext. 5555' of any fire conditions – REACT and listen for announcements. Provide instruction for other staff in your area.
2. If fire is present attempt to rescue the occupant or control the fire situation and implement the
code RED protocol. You must evacuate that room and adjacent rooms very quickly and close all doors
3. Notify the switchboard at ‘ext. 5555’ notify them of the fire condition in your area. Be sure to
provide details of your remediation strategy and what was done to mitigate reignition.
4. Once rooms have been checked and no fire condition is present, advise patients to stay in their rooms and await instruction. In the event a patient or visitor is being uncooperative be sure to notify the switchboard at ‘ext. 5555’.
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1.1.1First Stage Alarm Specific Location Evacuation H.E.A.T During a first stage alarm there may be the need to evacuate an isolated unit or building. All staff is advised to refer to their area-specific Code Heat Evacuation procedures. If immediate assistance is critical, the Area in Charge Person is to request Switchboard to announce activation of H.E.A.T (Hospital Evacuation Assistance Team) & the area in need. On hearing the announcement all clinical and non-clinical areas are to deploy one staff member to the evacuation unit and report to the Area Charge Nurse there for appropriate assignment Areas or buildings that are required to evacuate shall proceed by using the safest route to ensure their safety;
The decision for further evacuation shall be made in conjunction with the Hamilton Fire
Department, who, upon their arrival shall assume a unified command with the hospital Incident
Manager.
1.2 Second stage alarm
Sounds at a rapid 120 bells / minute and if sounded if there is a need to evacuate the entire
building. Once the second stage of the alarm is initiated your total building evacuation
procedures come into effect. An overhead page / emergency code pager alert will be made
announcing:
“Code Green is now in Effect”
Second stage- Fire Alarm System Malfunction Procedure: Should the fire alarm system malfunction and cause and accidental activation of the Stage
Two – Total Building Evacuation alarm, the following procedure will be initiated.
1) An overhead page / emergency code pager alert will be made announcing:
“Code Green Standby”
This will be announced 3 times at 5 minute intervals until the “All clear” is given. All Wards and
Departments are to standby and maintain a high state of alert and preparedness to initiate an
evacuation should it become
2) Should a need to initiate a Stage Two - Total Building Evacuation occur an overhead page /
emergency code pager alert will be made announcing:
“Code Green in Effect”
This will be announced 3 times at 5 minute intervals and will be made in conjunction with the
stage two – total building evacuation alarm bells. All areas need to be familiar with their fire
emergency evacuation procedures. Refer to Appendix A HHS Code Green & H.E.A.T
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2.0 Evacuation
You must be prepared for evacuation. Know your exits, evacuation routes and procedures. After each
drill review, maintain and update your area-specific Code Red Procedures.
Areas of the Hospital are divided through compartmentation or special separations. These separations
are found between sleeping rooms, treatment rooms, departmental areas and corridors (smoke barrier
doors, every 75 feet along corridors).
The fire separations confine the fire to a specific area (point of origin) and take approximately 1 hour to
spread beyond an enclosed separation.
Compartmentation is only effective if the doors and windows are kept closed thereby confining the fire
and the smoke to the room of origin. Effective compartmentation allows time to stabilize and evacuate
patients and staff from the immediate danger zone and for the fire team / fire dept. to initiate fire
suppression procedures.
Staffing Levels with respect to fire evacuation procedures within the Hamilton Health Sciences
Corporation sites shall comply with the Office of the Fire Marshall and Emergency Management
(OFMEM), Ontario, technical guideline Staffing Levels in Care Occupancies, Care & Treatment
Occupancies and Retirement Homes (TG-01-2013).
2.1 Preparing for Evacuation
• If time allows generate patient and staff evacuation lists.
• Under no circumstances are patients to be moved in their beds. This constricts hallways and
corridors, endangering all of the area occupants.
• The placement of wet towels, blankets or sheets at the bottom of a closed door, assists with restricting
a rapid transfer of smoke and generates extra time with which to complete area evacuation.
• Adjacent Wards and Areas are advised to identify a buddy area who can provide mutual aid
assistance in a Code Red. This Code Red mutual aid assistance program allows for the immediate
addition of personnel from the adjacent areas to assist with the evacuation of an area that is in immediate danger.
• Your evacuation protocols are not to assume that unlimited assistance is available from the Fire
Department or other areas- exterior to your own. In most circumstances assistance is available;
however, there may be situations where you are required to complete your evacuation protocols with
the resources at hand.
• Ensure that you have ample space available in your evacuation staging areas to enable you to assemble your patients and resources.
• If time allows, prepare and gather priority medical resources (this includes blankets) that your area
deems necessary to maintain a minimum level of care for your patient population if evacuation
becomes necessary.
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Remember, once evacuation protocols have been initiated there are no guarantees that you are able
to gain access to another inpatient care area. Your resource items must be essential items only and
easily transportable (use a laundry or garbage bags).
• Have two horizontal evacuation routes, one primary route and one secondary route. These routes
are always in the opposite direction of each other and in many cases, the secondary route entails
traveling down the stairwell.
2.2 Progressive stages of evacuation
Progressive stages of evacuation in the event of heavy smoke contamination or a fire within your area
are: • room of fire or smoke origin, • then the adjoining rooms working out and away from the room of fire or smoke origin.
Affix masking tape at knee level from the door frame onto the center of the closed door of an
evacuated room to indicate that the room has been checked and cleared. Rolls of 2” masking tape
are contained within your emergency preparedness and evacuation resource kits.
2.3 Evacuation by Compartments
Once in the corridor between a set of smoke barrier doors this is a compartment and it is designed
as a point of refuge. By moving from compartment to compartment we can protect patients and
ourselves without transporting or moving too far. This is referred to as horizontal or horizontal
evacuation.
2.4 Horizontal Evacuation (Primary Evacuation Route)
To facilitate horizontal evacuation we need only move 3 or 4 compartments away from the danger
zone. Inpatient wards are advised to move toward an adjacent inpatient care area.
2.5 Vertical Evacuation (Secondary Evacuation route)
If you are faced with a vertical evacuation then movement is always down via the stairwell but
never up or below grade or ground level. It may be necessary, in this situation, to initially evacuate
to the exterior or outside of the building and then reenter via a main or side entrance.
Once you have arrived within another area-you follow their area-specific Code Red evacuation
routes and procedures. All Staff are reminded that in the event of any evacuation their assistance
may be required to aid in the movement of patients.
2.6 Second Stage Total Building Evacuation
During a second stage total building evacuation, staff are advised to refer to their area-specific Code
Green Evacuation procedures.
Total building evacuation entails exiting the building by the shortest route available. As with the
horizontal evacuation, there are always two routes planned, one primary and one secondary, each
in the opposite direction of the other.
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Staff must be prepared to apply maximum flexibility to their procedures. Evacuation routes may vary
but your destination does not.
Once a second stage evacuation is initiated all major resources, extra blankets, mattresses, medical
supplies, portable oxygen etc. are acquired from ground level areas only. The size of the fire or Hazard indicates the extent of the evacuation necessary. Horizontal evacuation can be self-initiated if there is a clear and present danger. The decision for further evacuation is made in conjunction with the Hamilton Fire Department who,
upon their arrival assumes command and control of the situation.
3.0 Responsibilities of Staff
3.1 Program, Service, Department Manager Responsibilities*
An effective area-specific Fire Safety Plan depends upon the knowledge, experience and
commitment of management personnel. Every supervisor must have a clearly defined role and the authority to respond appropriately. All new staff MUST receive training in the Fire Safety Plan before responsibilities can be delegated. Training for all staff members must be organized and be conducted at least annually. Conduct Unit/Dept. Code Red Fire Drill review at least monthly as required by law.
Unit / Department Manager
Ensures adequate staffing levels are sustained at all times to ensure that all functions can be
implemented as outlined in the Fire Safety Plan
• Ensures that Code Red area specific information is developed, current, and reviewed annually by
the Code Red Subcommittee • Designates an Area Code Captain responsible for fire safety; to maintain the area specific Code
Red Information (see EDM – HHS Area Specific Code Information Record Template) current &
available; to coordinate the regular training & education of Code Red to staff; to identify fire
hazards to the area Manager; complete and forward the necessary documentation to the Manager
for review. • Ensures all staff participate in monthly fire drills and required yearly in-services. • Ensures relevant documentation is completed (Code Red Fire Drill & In-service Staff Attendance
Records, Code Red fire Drill Summary Report, Annual Code Red Report). • Maintains a fire hazard free work area. • Shall identify and designate a Code Staging Area where staff shall report to in the event of an
Emergency Code such as a Code Red. • Ward Managers: will ensure that each in use isolation room be placarded on the patient corridor
side with a legible sign identifying it as an isolation room
*N.B. Medical Affairs is responsible for medical/midwifery staff, residents, interns and medical students
It is recommended that the Area-Specific Fire Emergency Protocols be broken down by protocol into
an instant access recipe / index card style system.
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3.2 Emergency Code Captain – Area Charge Person
The area Manager / Supervisor (or their delegate), is considered to be the Emergency Code Captain
(Area Charge Person) in their respective areas. The Emergency Code Captain (or delegate), is
responsible for coordinating and assigning personnel to carry out instructions in each area during a
Code Red condition. The Emergency Code Captain (or their delegate) should be easily and readily
identifiable by a safety vest.
Area Code Captain responsible for fire safety; to maintain the area specific Code Red Information (see EDM – HHS Area Specific Code Information Record Template) current & available; to coordinate the regular training & education of Code Red to staff; to identify fire hazards to the area Manager; complete and forward the necessary documentation to the Manager for review
The Area-Specific Fire Emergency Protocols are to be contained in the Area specific Emergency
Procedures Manual and is to be maintained and kept available by the Emergency Code Captain in
their respective areas.
BACK-UP COVERAGE
The integrity of the code captain program requires the cooperation of all staffs involved, even if just
following instructions. Daily communication between the team and assigning backup supervisory staff
to fill in where necessary should be accomplished as soon as possible
Placement of Infection Control Carts in Patient Corridors - Mc Master
University Medical Centre (MUMC)
Wards 3B, 3B-PEDU, 3C, 4B and 4C are permitted to locate isolation carts in the Ward corridors provided
the follow conditions are maintained at all times:
Patient corridors are to remain free of all other
obstructions/supplies/patient care accessories/laundry supplies/catering carts etc. not under transit or in use and under the immediate control of
hospital staff. Permanent storage of items/supplies is not allowed.
That each "in use" isolation room be placarded on the patient corridor
side with a legible sign identifying it as an Isolation room. Only
designated isolation rooms will be allowed to have an isolation cart
located adjacent to the room entry door in the patient corridor.
3.3 Area Staff
All staff return to their area via the stairwells only. DO NOT USE ELEVATORS unless
directed to do so by Fire Emergency personnel.
Staff are to move quickly but cautiously.
Approach stairwells and smoke barrier doors with due care and caution.
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Check to ensure that stairwells and beyond the smoke barrier doors are free and clear
of fire and smoke conditions.
Staff attending meetings at their home site immediately return to their respective areas.
Staff attending from other sites accompany home site Staff to their areas.
Further Intercompartmental movement is to be restricted to legitimate emergency
and urgent tasks only.
Staff already in their work area at the time of the alarm are to…
1. Sweep the work area and check:
• for fire conditions (smoke, heat, flame) • that all doors are closed • that all exits have clear access (clear corridors of all in use equipment and
carts – relocate Isolation Cart from corridor into the closest clean room) • that a portable fire extinguisher is available • inform the Emergency Code Captain (or delegate) as to who is present in the
work area • generate Patient and Staff evacuation list
2. Patients are evacuated in order of physical condition.
A. Ambulatory - minimum number of staff required to lead group to safe area;
B. Wheelchair patient (use improvised wheelchairs if necessary);
C Critical patients (those requiring the most resource to move) as they need to
be moved when the greatest amount of help is available – activate “HEAT”
protocol;
D. Those that resist.
3. Prepare important items for safekeeping or evacuation i.e. patient charts, priority
medical resources, and blankets. Items must not be cumbersome or constitute a
hazard during an evacuation. Staff are to maintain a hands free condition in order
to offer aid and assistance.
4. Designate a person to stand by the telephone and ensure that telephone use is
restricted to stat, emergency or urgent calls only. Confine inter-compartmental
movement to a minimum.
5. Ensure visitor, patient and staff movement are controlled.
6. Once staff are safely within their area they stay put unless there is a clear and
present danger, then the area-specific ‘Horizontal Evacuation Procedure’ is
initiated.
7. Review Horizontal Intercompartmental and Total Building Evacuation Routes. In-
Patient care areas - this review also includes “Lifts and Carries”.
8. STANDBY and await further instructions
9. REMAIN on emergency alert until the sounding of the all clear.
10. At the discretion of the manager or delegate staff may resume their duties within
the confines of their area only.
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Intercompartmental movement is to be restricted to legitimate fire and
medical emergency and urgent tasks only.
3.4 Telecommunications
On Smell of Smoke notification: • Pages HHS Fire Response Team (FRT), of "Smell of Smoke" level & location & awaits FRT
instructions
On Fire Alarm notification: • Confirms alarm and location • Calls Fire Dept. (911) & gives building address & alarm location • Pages FRT of Code Red level & location • Announces overhead as directed Code Red status Standby ; In-Effect; Level/location/zone • Announces overhead as directed Code Green status Standby, In-Effect, Level/location/zone
• If FRT confirms fire, contacts those on notification list • Others (as directed)
• Repeats overhead announcement every 5 minutes • Announces instructions and orders under the direction of the FRT and Hamilton Fire
Department • Alarm system is monitored by Alliance Protection. Upon receipt of alarm the monitoring
company calls 911. After the 911 call the Alarm monitoring company calls back to Switchboard
to alert and verify alarm condition
3.5 HHS Fire Response Team (FRT) Composition
While all staff have a significant role in responding to fire alarm situations, each site has
a core Fire Response Team that takes the lead in responding to fires & alarm situations.
Fire Response Team members include the HHS Fire Marshal/Fire Prevention Life Safety Officer (if on site), Security, Engineering staff, electricians,
plumbers, select Customer Support Service staff & other individuals with fire
protection/containment skills. Respiratory Therapy is also part of the Fire Response Team to manage areas with oxygen supplies. The HHS Fire Marshal/ Fire Prevention
Life Safety Officer is the Fire Response Team Lead if on site. Otherwise Security
takes the Lead role.
3.5.1 HHS Fire Response Team Role
• Go to alarm location & find source of smoke/fire • If fire confirmed, ensure pull station activated and a call is made to telecommunications • A small fire may be extinguished by the use of a portable fire extinguisher, only if the
smoke or fire dose not present danger to the operator, and the operator is trained in the
use of a fire extinguisher. • Contain / smoke / fire, until Fire Dept. arrives and assumes control of firefighting activities. • Assist in evacuation of fire area if required
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3.5.2 Engineering:
• As directed by Fire Response Team Lead, notifies Telecomm of status updates incl. "all clear" & area evacuation decision, destination & arrival
• All Air handling units within the quadrant in alarm immediately shut down on activation of
the fire alarm system. Under the direction of the Hamilton Fire Dept. Engineering staff
will adjust (shut down, startup) building services/systems as needed. This includes
manipulation of the air handling systems to create positive and negative pressure zones. • Resets fire alarm system following "all clear", arranges a Fire Watch in conjunction with
Security Services in the event of an alarm systems loss or zone isolation • Manages HHS' fixed & portable voice communication systems to facilitate Fire Dept.
response.
3.5.3 HHS Fire Response Team Lead Role
The HHS Fire Marshal/Fire Prevention Life Safety Officer is the Fire Response
Team Lead if on site. Otherwise Security takes the lead role. • Assumes control & directs Fire Response Team activities until Fire Dept. arrives. • Obtains info on area & any endangered persons. • Meets and briefs Fire Dept. on arrival, directs them to the scene and provides all
necessary keys (access and elevator control), and HHS two-way radios for Fire Dept.
use. • Communicates with Incident Manager & Area Charge Person. • Determines "all clear" status from Fire Dept. & informs Fire Response Team.
3.5.4 Respiratory Therapy:
• Manages & coordinates transportation of oxygen and medical gas supplies in affected
area(s).
3.6 ADMINISTRATION RESPONSIBILITIES
. Site Director or Administration on-call
1. Take on the role as Clinical Lead;
2. Work collaboratively with the Code Red Response Team providing patient care expertise and direction
required;
3. After hours, weekends and STAT holidays the Administrator-on-call shall work collaboratively with the Code
Red Response Team Lead and assume the role of Clinical Lead;
4. Notify Executive-on-call in the event that the Code Red Alarm involved an actual fire and there is/are: Any
injuries; or any physical/property damage; Evacuation is required
5. Upon notification of the incident to the Executive-on-call it shall be determined if the initiation of the
Incident Command Centre is required. Executive-on-call shall take the lead of Incident Manger upon initiation
of the IMS Command or as deemed necessary by the incident.
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Executive Team
1. In the event of a major fire being confirmed by the Manager/Director or Administrator-on-Call, the Executive –on
Call shall be paged or called. A decision will be made at that time if initiation of the IMS Command Centre is
required;
2. Assume the role of Incident Manager during a confirmed fire situation. The Executive has the ability to delegate
this position as the situation warrants.
3. Work collaboratively with Hamilton Fire Department.
HHS IMS Command Structure
The Incident Management System (IMS) is used to manage all codes, emergencies or disasters. It
includes the following functions in separate or integrated roles depending on the available resources at the
time:
Incident Commander/Manager role · Oversees coordination & overall management of the emergency/disaster response &
recovery; · Organizes & directs the Emergency Operations Center (Command Center or Command
Post) & IMS role assignment; · Chairs IMS command meetings; · Organizes debriefings & identifies areas for improvements.
Operations Chief role · Organizes, directs & oversees the Operations Section i.e. Treatment areas,
Patient areas, Tracking, Facility Operations and Support Services; · Implements the action plans directed by the IMS Command Team.
Planning Chief role · Organizes, directs & oversees the Planning Section i.e. provision of situation analysis,
long-range & contingency planning, resource analysis & planning, data collection &
analysis, identification of technical specialists/experts, recovery planning and
documentation;
Logistics role · Organizes, directs & oversees activities associated with obtaining resources
(staffing, supplies, equipment, facility) & maintaining the physical environment/facility
necessary to support implementation of the action plans. Logistics includes Nutrition,
Materials/Supplies, Equipment, Sanitation/ Housekeeping, Transportation/Portering &
the Labour Pool.
Finance & Administration role · Organizes, directs & oversees activities related to monitoring & tracking costs
associated with the event & implementation of the action plans it include Costs,
Compensation/Claims and Time/Payroll.
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While the IMS Command Team can meet anywhere, in events where communication with internal/external areas is critical, the Emergency Operations Center (EOC), also known as
the Command Center, is activated. It is located where the IMS Command Team converge
to oversee an event, develop/review the situation, issues and strategies for its management
& recovery. In a multisite emergency or disaster, there is both a Central EOC & Site EOCs.
All duties and responsibilities will be fulfilled on a 24/7 basis utilizing onsite personnel and on-
call fan-out protocols.
4.0 Fire Response (In Case Of Fire)
4.1 REACT
On Discovering Fire or Smoke – Don’t Panic
R Remove all room occupants Patients, visitors, or staff must be removed to a safe
distance from the fire of origin horizontally on the same floor through at least one fire separation door.
E Ensure room doors shut. That the doors and windows to the room of fire origin are
closed, leaving lights on
A Activate Fire Alarm. Pull the nearest fire alarm pull station
C Call 5555 (switchboard) Confirm Code Red, and your Location,
T Try and Extinguish fire if possible if you have been trained to do so with appropriate
firefighting equipment. Check the exterior of the door and frame for heat before re-entering the room. Always try and fight a fire in a Team of Two both armed with an extinguisher. If you have the slightest doubt, stay out and concentrate your efforts on evacuating patients.
Smell of Smoke
5555 is to be called for all and any untraceable burning smells
If you see visible smoke or fire – REACT accordingly
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4.1.1 First Stage Alarm: Staff, Patients, Visitors
4.1.2 Second Stage Alarm – Evacuation:
On notification, Staff in Evacuating Area… Assemble in area code staging location Receive & complete assigned tasks & report updates to ACP Prepare patients for evacuation Remain calm, walk rapidly, but do NOT run. Reassure patients & visitors, & in a calm manner quickly
evacuate them from the area. Keep movement on right side of corridors & stairwells to avoid blockage Check patient condition and emotional health periodically
When teams no longer needed, ACP will direct unit staff to the evacuation destination to help care for
evacuated patients & release other staff to return to their home base.
Do not leave until released from duties by ACP On arrival to destination area follow direction of receiving ACP or delegate
Refer to Appendix A: HHS Code Green & H.E.A.T for amplifying information
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4.2 Types of Fires and Extinguishers
An easy way to remember how to use a fire extinguisher is to apply the P.A.S.S. acronym. P – Pull the extinguisher handle pin. A – Aim the hose of the extinguisher at the base of the fire. S – Squeeze the extinguisher handle. S – Sweep the extinguisher hose side to side to ensure full fire extinguishment. This procedure and extinguishment should only take 5 – 10 seconds to complete.
Blankets
These are extremely valuable for use as an improvised fire extinguisher to smother a fire or wrap
around a person whose clothing has ignited.
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4.3 Fire hose
Fire Hoses are restricted to trained persons only
4.4 When to Fight a Fire – Ensure Alarm has been Activated First
Fight the fire only if all of the following are true:
• the fire is small and confined to the immediate area where it started (e.g. waste basket, electrical appliance, couch cushion etc.)
• you can fight the fire with your back to the door at all times
• your fire extinguisher is rated for the type of fire you are fighting and it is in good
operational condition.
• you have had the required training in the use of fire extinguishers and are confident that
you can operate it effectively.
• If possible fires should be fought in teams of two with both staff members armed with
their own extinguisher.
If you have the slightest doubt about whether or not to fight a fire then: Get Out and Stay Out, closing and sealing the door behind you.
FIRE EXTIGUISHMENT, CONTROL /CONFINEMENT Fire Extinguishment
Fire Extinguishment is primarily the responsibility of the Fire Department. The production of toxic fumes within the building makes firefighting potentially dangerous, particularly if a large amount of smoke is being generated. Only after ensuring that the alarm has been raised and the Fire Service notified, a small fire can be extinguished by a trained person(s) familiar with an fire extinguishers operation.
5.0 Fire Safety for Occupants
5.1 Staff Responsibility
It is the responsibility of all personnel to read and be familiar with the procedures and
protocols to be followed in the event of fire or other emergencies. All personnel are to follow
the instructions of, and cooperate with the requirements of the Ontario Fire Code, Ontario
Building Code, Corporate and area-specific Code Red Protocols and Procedures.
All personnel are responsible to ensure that they know the following: • the location of fire extinguishers; • the class / type of fire each extinguisher is designed to extinguish; ; • the location of the fire alarm pull stations and how to operate them; • the location of exits; • that all staff participate in the monthly code red drills and reviews; • the procedures to follow in the event of a fire as directed in the Corporate and their
Area-specific Code Red Orders; • the location of designated area-specific assembly areas to report to when evacuating
the building;
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• that all fires are reported regardless of size of fire or whether or not it has been
extinguished; • that it is a serious offence to tamper in any way with fire and life safety equipment,
including smoke detecting devices and fire extinguishers; • when fire and/or life safety hazards are observed they are reported immediately to your
supervisor; • fire prevention measures appropriate to your work environment; and • inform your supervisor if you require special assistance to evacuate the building.
5.2 Occupant / Staff Training
All personnel working within buildings of the Hamilton Health Sciences are instructed by their supervisors as to their individual responsibilities for general fire safety of the building and its occupants as follows:
All new employees attend a Corporate Fire Safety Orientation session. A copy of Corporate and area-specific Code Red procedure are available on HHS Emergency Disaster Management Site to read and they are also briefed by their supervisor as to:
the location of fire alarm pull stations, fire exits and fire extinguishers within and adjacent to their place of work;
every staff/affiliate member of HHS buildings is responsible to review Code Red monthly:
the location and contents of the Corporate and Area-specific Code Red protocols and procedures;
fire prevention measures appropriate to their work environment and;
complete a on line eLearning of Fire Safety Training session (annual)
6.0 Fire Hazard Control
6.1 Building Decorations
• Only fire retardant/flame resistant decorations and decorating materials can be used in HHS
buildings.
• Open flame decorations, such as candles and sparklers are not permitted
• Exits must be maintained free of obstructions and are used for no purpose other than exiting.
• Fire retardant chemicals must not be used on decorative materials (Because it is virtually impossible
to attain an acceptable degree of fire retardant using fire retardant chemicals on paper and most
other materials)
• Fire retardant chemicals applied at point of manufacture only are acceptable.
• Natural Christmas trees, tree boughs and hay bales are not permitted in HHS buildings.
• Decorations must not be placed on or within one meter (3 ft.) of electrical lamps, heating appliances,
heating piping, etc.
• Decorations should not be hung on doors or door casings • Decorations should be hung up out of
reach.
• Decorations should not be hung from ceiling tiles or their supporting tracks. This may impact on fire
separation barriers, and create pathways for smoke migration.
• Fire hazards such as straw and/or hay are not permitted inside HHS buildings.
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• Electrical lights - used for decoration must be of an approved type and must pass inspection by HHS
electricians.
• Check each string of lights for broken or cracked sockets, frayed or bare wires and loose connections
• Decorative (Christmas, Halloween etc.), lights should only be used in common areas, and installed
in such a way as to eliminate fire and/or tripping hazards. This type of decoration should not be
installed in patient rooms. • Flashing or blinking type lights should not be used anywhere. This type of lighting has been
known to bring on seizures in certain patients.
• Avoid purchasing electrical decorations, extension cords and power bars from “dollar stores”. These
items have been known to be counterfeit and are dangerous as they may not meet Canadian Safety
Standards
6.2 General / Personal Housekeeping
Rubbish and waste material Contribute too many fires and are frequently classed as fire hazards. Except in cases of
spontaneous ignition, they do not actually cause the fire but they can furnish the fuel that is
easily ignited by small sources of heat and allow the fire to spread quickly.
Maintenance of a high standard of housekeeping is essential in the prevention of fire.
Indoors Proper and regular disposal of waste paper and other combustible material is important. At
the end of each work day, waste material is removed from the building and deposited in the
bulk containers provided.
Outdoors Cleanliness and good housekeeping are just as essential outdoors, therefore, rubbish and
waste materials is not allowed to accumulate.
Oily Waste Oily waste, oily clothing, wiping rags, and other materials that are contaminated with
flammable or combustible liquids are subject to spontaneous ignition, and are required to
be stored in an oily waste can bearing the label of the Factory Mutual Laboratories. The
oily waste cans are to be emptied at the end of each working day and the oily waste
removed from the building and stored in metal containers.
6.3 Storage, Handling And Use Of Flammable Liquids
This section applies to the storage, handling and use of flammable liquids in portable
containers inside buildings.
Copy of the Code Brown Spill Procedure to be posted in areas that handle or use flammable
or combustible liquids. See Appendix D
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Flammable liquids are those having a flash point below 100 deg. F, such as gasoline, alcohol and acetone.
Storage Precautions for Flammable Liquids
Additional requirements are necessary for the safe storage and use of liquids that have one
or more of the following properties: • unusual burning characteristics;
• subject to self-ignition when exposed to air;
• highly reactive with other substances;
• subject to explosive decomposition; and
• other special properties that indicate a need for special safeguards.
Under Section 4.1.7.6.(1) of the Ontario Fire Code all Recirculating Ventilation Systems
(Fume hoods), require that a fail-safe vapour detection and alarm system be installed to
continuously monitor the flammable vapour concentration in the exhaust air. The Faculty of
Health Sciences has installed “Ventalert” systems in the University laboratory’s in
compliance with the Code. Information on this system and is available from MUMC
Engineering Services.
• flammable liquid containers and storage cabinets are not stored near exits, stairways or
other areas normally used by and for the safety of personnel.
• storage facilities are approved by the HHSC Fire Prevention & Life Safety Officer and/or,
if required, the Fire Prevention Bureau of the Hamilton Fire Department.
• where required for ready use, quantities of flammable liquids not exceeding the
quantities allowed by Section 4 of the Ontario Fire Code, may be stored in buildings.
• storage is in approved containers and placed in labeled metal flammable liquids storage
cabinets indicating that no smoking or open flames are permitted in the area.
• flammable liquids in quantities exceeding the quantity allowed for ready use by Section
4 of the Ontario Fire Code, are to be stored only in approved compounds or specially
designed rooms or buildings.
Handling of Flammable Liquids
• the dangers associated with dispensing and handling of a low flash point liquid are
brought to the attention of all concerned by the area supervisor. • flammable liquids are not handled, drawn or dispensed where flammable vapours may
reach a source of ignition; • due to the volatility of low flash point flammable liquids, extreme caution must be
undertaken when dispensing liquids from one container to another or refueling
lawnmowers, hedge trimmers, etc. • refueling is not done inside the buildings
• flammable liquids having flash points below 100 deg. F are not used as a cleaning
solvent.
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6.4 Open Flame Hazards Control
A WELDING / HOT WORK permit is required for all cutting and welding and/or use of open
flame.
Staff engaged in HOT WORK will ensure that a fire extinguisher is available and instantly accessible at all times.
6.5 Unobstructed Access to Exits – Clear Corridors Equipment and Carts Corridors must be kept free and clear of all items and equipment except for in use (physically manned) equipment. The only acceptable items that are permitted within the Patient Care Ward corridors are: manned/in use Medication Carts, Cleaners Carts and Patient lifts. All other equipment including Lifts, Medication and Cleaners Carts, when not in direct use, shall be removed from the corridor and stored safely within a room.
Patient Emergency Rest Stations (Chairs)
Patient emergency rest station chairs shall remain in the upright – closed position when not in use.
6.6 Electrical Equipment And Appliances
Electrical Equipment
• is installed and maintained in accordance with requirements and standards of the Electrical Code and applicable construction engineering technical orders.
• electrical equipment and appliances are of a type approved by the Canadian Standards
Association (CSA), Underwriters Laboratories of Canada (ULC), Factory Mutual (FM),
Underwriters Laboratories Inc. (ULI). • installation and maintenance of electrical wiring, equipment and appliances is not
carried out by personnel other than authorized HHSC electricians and technicians or
competent electrical contractors approved by HHSC.
Appliances
• privately owned electrical appliances are of an approved type (see: electrical equipment
and appliances section above). • it is the owner’s responsibility to ensure that all appliances are operated safely and
maintained in good electrical and mechanical condition. • electrical kettles are equipped with an automatic shut off feature.
6.7 Extension Cords
• only approved flexible extension cord sets are used • the cord is not permitted to carry more than its rated current carrying capacity. • extension cords are not to be supported by staples nor looped or tied around metallic
objects such as nails, metal pipes, etc. • extension cords are maintained in good condition without cuts, frays or kinks and are
maintained as manufactured without alteration of any kind.
• Flexible extension cords must never take the place of permanent wiring; they are not
designed or intended for permanent installations
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• Once the task has been completed, the cord should always be disconnected and properly
stored away for future use
Hazardous Locations Only wiring, equipment and appliances approved for use in a hazardous locations are used
for that purpose.
6.8 Portable electrical Heaters
Portable space heating devices shall be prohibited in all health care occupancies unless both of the
following criteria are met.
1. Such devices are used only in nonsleeping staff and employee areas. 2. The heating elements of such devices do no exceed 212F.
Only electrical portable heating devices with an engineering approved sticker are allowed to be used in
the hospital. When authorized for use the manufacturer’s recommendations for operation must be
followed.
Heaters must be CSA, ULC or UL approved
Heaters must have an auto shut off if tipped over, and thermostat and overheat protection.
Heaters must be kept at least 1M (3 feet) away from combustible material.
The heaters must be kept out of the exit routes.
Never plug a heater into a power bar.
Never use a heater with a damaged electrical cord.
Heating element must not be exposed
Heater should be plugged directly into appropriate receptacle
Heater must never be left unattended
Heaters must be turned off when leaving the room.
The total number of portable space heaters deployed within any given floor area must be minimized so as
not to overload the electrical circuits. Overloading the circuits may trip the breakers, which could mean a
temporary or total loss of power to the Area.
Recommended Unit Type: Ceramic or Oil Filled
If you use space heaters use them with care.
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7.0 Fire Safety Maintenance Regulations Ontario Fire Code
Before working on the Code Red fire system the occupants of the building must be notified that
maintenance is being preform on fire system and staff are to call 5555 if there is smoke or fire.
When any life safety system is under test, repair or shutdown, Facilities Management shall notify the alarm-monitoring agency advising them of the situation and not to initiate communication to the Hamilton Fire Department should an alarm condition be received.
The Switchboard operator will also announce overhead via the paging system that the fire alarm system is being tested.
Should a fire start while the test or drill is being conducted, Switchboard shall be notified as per the normal REACT procedure and it will be the responsibility of Switchboard to call the Fire Department advising them of the actual fire situation;
During any shutdown of fire protection equipment and systems for part thereof, the Security shall provide hourly rounds of the affected areas. This shall be evidenced by a log book recording these hourly rounds
Engineering - Fire Safety Maintenance Requirements
Definitions:
Check means a visual observation to ensure the device or system is in place and is not obviously
damaged or obstructed.
Inspect means physical examination to determine that the device or system will apparently perform in
accordance with its intended function.
Test means operation of device or system to ensure that it will perform in accordance with its intended
function.
Owner means any person, firm or corporation controlling the property under consideration
Chief Fire Official means the municipal Fire Chief or a member of the Fire Department designated by
him or, where there is no fire department, such assistance to the Ontario Fire Marshall as the Fire
Marshall may designate for the municipality or territory without municipal organization.
DAILY 1. Check Exit signs to ensure they are in a clean and legible condition 2. Check Exit lights to ensure they are illuminated and in good repair 3. Check Torches, regulators and welding equipment for defects 4. Check Fire alarm system AC power lamp and trouble light 5. Check Central alarm and control facility 6. Check Tank heating equipment, enclosure and water temperature for fire protection water tanks
during freezing weather. 7. Check Temperature of fire pump rooms during freezing weather.
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WEEKLY 1. Check hoods, filters and ducts in ventilation systems subject to accumulation of combustible deposits 2. Check that sprinkler system control valves are open 3. Check that dry pipe sprinkler systems air pressure is being maintained 4. Inspect valves controlling fire protection water supplies 5. Check the water level and air pressure for fire protection systems pressure tanks 6. Inspect relief valves on air and water supply lines of fire protection system pressure tanks 7. Check water level in fire pump reservoirs 8. Inspect and operate all fire pumps*
Check all components of emergency generator system and operate the generator set under at least 50%
of the rated load for 30 minutes *
Test maintain emergency power systems as per CSA-C282
MONTHLY 1. Inspect all doors in fire separations 2. Inspect and test emergency lighting system, batteries, units and lamps * 3. Conduct fire alarm drills for supervisory staff in day care centers and health care facilities 4. Test all, welding and cutting equipment * 5. Inspect all portable fire extinguishers (as per NFPA 10-1990) 6. Test the fire alarm system and check all components including standby batteries * 7. Test the voice communication system * 8. Inspect all fire hose cabinets 9. Test the sprinkler alarm * 10. Inspect the water level in gravity fire
EVERY 2 MONTHS 1. Test sprinkler system central station connections *
EVERY 3 MONTHS 1. Test all fire safety devices in high buildings as defined by subsection 3.2.6. of the Ontario Building
Code 2. Test fire fighters elevator for proper operation. 3. Inspect the priming water level for dry pipe systems
EVERY 6 MONTHS 1. Inspect fire protection systems for commercial cooking equipment * 2. Test gate valve supervisory switches and other sprinkler and fire protection system supervisory
devices * 3. Check and clean crankcase, breathers, govenors and linkages on emergency generator sets 4. Inspect and maintain special extinguishing systems 5. Inspect elevators in an elevator shaft that is intended for use as a smoke shaft and ensure they
function as designed under an alarm condition *
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ANNUALLY 1. Inspect all fire dampers and fire stops flaps 2. Inspect all chimneys, flues and flue pipes 3. Inspect disconnect switches for mechanical air conditioning and ventilation systems. 4. Clean chimney spark arresters 5. Check smoke alarms shall be maintained in operating condition by the owner 6. Conduct maintenance procedures for fire extinguishers. 7. Test fire alarm system by qualified personnel acceptable to the Chief Fire Official (as per CAN/ULC
S536 M97) * 8. Conduct a complete test of the voice communication system by qualified personnel acceptable to the
Chief Fire Official * 9. Inspect all standpipe hose valves 10. Remove and re-rack all standpipe hose 11. Inspect all exposed sprinkler system pipe hangers 12. Inspect all sprinkler heads 13. Inspect dry pipe water priming level 14. Inspect fire department connections 15. Conduct sprinkler system alarm test using the most hydraulically remote test connection * 16. Conduct a dry pipe system trip test * 17. Conduct a main drain flow test of the sprinkler system water supply * 18. Inspect fire protection water supply tanks 19. Inspect the cathodic protection of steel fire protection water tanks 20. Inspect all parts of a gravity fire protection water tank 21. Conduct a fire pump flow test 22. Inspect and flow test all fire hydrants 23. Conduct general engine and generator maintenance and engine tune-ups for emergency generator
sets 24. Inspect closure at the top of air-handling used for venting 25. Test smoke control equipment
EVERY 2 YEARS 1. Check all steel fire protection tanks for corrosion 2. Inspect all fire protection water supply tanks, connected to a non-potable water supply, for the
accumulation of sediment. 3. Check valve adjustments and torque heads for emergency generator engines
EVERY 3 YEARS 1. Clean and service injector nozzles and check valve adjustments for emergency generator diesel
engines
EVERY 5 YEARS 1. Hydrostatically test carbon dioxide and water type extinguishers* 2. Hydrostatically test dry standpipe system * 3. Inspect fire protection water tank connected to a portable water supply, for the accumulation of
sediment 4. Check insulation of generator windings 5. Inspect closures in vent openings into smoke shafts
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EVERY 6 YEARS 1. Replace the extinguishing agent in dry chemical fire extinguishers
EVERY 12 YEARS 1. Hydrostatically test dry chemical and vapourizing liquid fire extinguishers*
EVERY 15 YEARS 1. Inspect dry pipe sprinkler systems for pipe obstruction - flush the system when necessary
AS REQUIRED 1. Check doors in fire separations to ensure they are closed 2. Check lint traps in laundry equipment 3. Ensure streets, yards and private roadways that are provided for fire department access are kept
clear 4. Check corridors and ensure they are maintained free of obstruction 5. Clean any combustible dust producing operations 6. Clean residue in spray booths 7. Vacuum clean and dust any dry powder finishing operations 8. Inspect, clean and maintain all industrial ovens and associated duct work 9. Inspect sprinkler system auxiliary drains 10. Maintain smoke control equipment in a manner to ensure satisfactory operation 11. Inspect and Test all equipment used in conjunction with smoke control measures * 12. Inspect and Test all equipment used in conjunction with smoke control systems *
* THESE ARTICLES REQUIRE WRITTEN RECORDS TO BE MAINTAINED
NOTE: WHENEVER A DEFECT OR DEFICIENCY IS DISCOVERED IN ANY FIRE AND LIFE SAFETY EQUIPMENT, AS A RESULT OF THESE MAINTENANCE REQUIREMENTS, CORRECTIVE ACTION MUST BE TAKEN IMMEDIATELY. DURING ANY SHUTDOWN OF FIRE PROTECTION EQUIPMENT AND SYSTEMS OR PART THEREOF, THE ELECTRICAL
SUPERVISOR OR DESIGNATE WILL ARRANGE WITH HHS SECURITY FOR HOURLY ROUNDS OF THE AFFECTED AREAS TO BE CONDUCTED. A LOG BOOK RECORDING THESE HOURLY ROUNDS IS TO BE MAINTAINED. THE PERTINENT INFORMATION
REGARDING SYSTEMS SHUT DOWN WILL BE COMMUNICATED TO THE HAMILTON FIRE
DEPARTMENT DISPATCH AT (905) 546 – 3333 ext. 6. Before and After System Shut Down
Alarm system down for maintenance signage to be posted at the primary site entrances
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Appendix A
HHS Code Green Response Procedures for evacuation and evacuation of persons needing assistance
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HHS Code Green Response Plan
Area Charge Person (ACP) Determines need to evacuate area/unit
Calls Switchboard x5555 (x7777@ SPH) (x400@WLMH)
Identifies site, code, exact location, evacuation destination & if H.E.A.T.
(Hospital Evacuation Assistance Team) assistance needed
Switchboardo Notifies Site Dir./Dir on-call/SAM & others on notification listo Announces x3 code on overhead/paging +H.E.A.T. activation o Follows Incident Manager direction
Is situation contained?Yes No
Incident Manager (Site or Director on Call)o Ensures Manager, Director, Medical Lead of affected area notifiedo Determines need to activate Command Center in consultation with
Site or VP on-callo Determines need to further escalate Code Green to Standby or
In-Effect for specific floors, wings or building & directs evacuation sequence (see Appendix B for Building Evacuation)
o Notifies Switchboard to announce Code Green Alert, Standby, In-Effect or All Clear as appropriate.
On “All Clear” notification… Areas not impacted resume normal duties. Areas impacted (e.g. evacuated or in refuge areas) await direction from Incident Manager on how to proceed/
resume operations/services
Updates Incident Manager of evacuation status
On announcement of a (Controlled) Code Green Standby... Areas prepare pts & staff for evacuation.On Command Center direction... Evacuating In-Patient Care Area(s): 1. Print & complete Patient Evacuation Worksheet for each inpt.2. Submit Worksheet to designated staff to collate info on hardcopy of Code Resource Status Report & submit info via online Code Resource Status Report to Command Center to coordinate support.Evacuating Out-Patient Care Area(s): 1. Print & complete Patient Evacuation Worksheet for any outpt unable to leave bldg immediately (e.g. needs pick up by next of kin)2. As aboveAll Other Pt & Non-Pt Areas (e.g. Support & Admin. Depts):1. Complete & submit online Code Resource Status Report based on ability to deploy resources (staffing, equipment, supplies) to assist evacuating area(s). This information is reviewed by the Command Center to coordinate distribution of resources to evacuating areas.For Code Green (Controlled) In-Effect …Command Center will notify & direct evacuation of areas in specific sequence based on risk & need & request completion of online Bed Status Report &/or Pt Evacuation Location Status Report as needed.
Security (or designate @WLMH) o Go to scene to assess &
provide assistance (if able)o Meet & escort external
emergency response team o Notify Parking to put parking
gates in “up” position (if applicable)
o Activate Access Control Officers to keep key entrances clear & help control traffic flow
o Manage external Hospital emergency access routes
o Liaise with Command Center/Incident Manager
Follows Code Green STAT Action Checklist (see p2)
On discovery of an immediate & serious hazard to occupants of a room or area… Staff: Immediately remove all occupants from room of origin first, then adjacent & opposite rooms; proceed to nearest safe, staging area & notify the Area Charge Person (ACP) for further direction
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CODE GREEN–STAT Action Checklist
On discovery of an immediate & serious hazard to occupants of a room or area
in…
Out-patient Care areas (incl. Physician office areas) or
Non-Patient Care areas (e.g. Support & Administrative Depts.)
Assemble & account for all occupants; proceed to assembly area (Cafeteria) to
await further direction from Incident Manager
IN-PATIENT Care areas…
On discovery of an immediate & serious hazard to occupants of a room or
area...
Staff: immediately remove all occupants from room of origin first, then adjacent &
opposite rooms & proceed to nearest safe, temporary staging area & notify the
Area Charge Person for further direction.
On notification, Area Charge Person (ACP) in Evacuating Area:
1. Put on ACP vest;
2. Ensure all occupants are cleared from immediate danger & accounted;
3. Determine risk & extent of evacuation necessary, evacuation route &
destination. Evacuate everyone to the same destination if possible to
facilitate tracking of occupants & equipment
4. Assemble all staff to quickly debrief, disseminate action plan & assign staff
tasks & establish teams
a. Determine #of staff available & additional staff needed to assist with
evacuation based on patient census & mobility. Calculate & delegate:
2 staff to escort groups of 6-8 ambulatory patients;
1 staff per patient in wheelchair or 2 if using rolling office chairs;
4 staff per patient in bed or stretcher;
2-4 trained staff per resistant patient (e.g. Fire Response Team or Fire Dept)
or for isolation patient (e.g. trained staff with PPE)
b. Prepare patients for evacuation:
For Ambulatory patients- have staff instruct ambulatory patients put on
coats & shoes, take assistive devices (e.g. glasses, hearing aids, dentures) &
line up outside their rooms with their bed blankets wrapped over their
shoulders The Escort Teams will collect them in groups of 6-8, instruct them
to form a chain by holding hands or placing their hand on the shoulder of the
person in front of them & following the lead staff escort to the destination
area. The second staff escort follows at the end of the line to ensure no one
is lost and to identify any problems. Blankets are both for comfort & as a
means of transport if patients become non-ambulatory & need to be pulled
on the blanket.
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For Wheel chair patients- if rolling office chair used, ensure chair is pulled
not pushed with second staff person keeping patient’s legs off floor using belt
or bed sheet.
For Bedridden pts - move only critical pts with beds. If authorized to use specific
elevators, first move critical & bedridden pts
For those resisting to leave notify Fire Response Team or Fire Dept. to
assist
c. Establish Staff Evacuation Teams
i. Transport Teams for Ambulatory, Wheelchair & Bed/Stretcher patients;
ii. Corridor teams in key areas to clear corridors, doorways/exits & form a
brigade for horizontal transport of patients to destination
iii. Carrying Teams in stairwells for vertical evacuation if applicable;
iv. Oxygen Teams for collecting & distributing portable oxygen, ventilators &
ambu bags;
v. Equipment Teams for collecting & distributing wheelchairs, office rolling
chairs, Collect & distribute essential evac equipment e.g. wheeled chairs,
blankets etc.
vi. 2 Triage Nurses- one for evacuating area to coordinate sequence of
evacuation (i.e. ambulatory patients first, then wheelchair & finally
patients in beds or stretchers. The other Triage nurse will triage patients
on their arrival in the destination area for further transfer (e.g. ICU, ER) or
treatment of injuries
vii. 2 Trackers- one at exit of evacuating area and one at entrance of receiving
area who account for all occupants & identify if anyone missing;
viii. Support Teams who collect and move any needed supplies in bulk (e.g.
charts, kardexes, medication administration records, Medication carts)
ix. 2 Room Checkers who check rooms after emptied for stragglers, close &
tape doors at knee level. They check closets, washrooms, & under beds,
etc., where a frightened or disoriented person might hide.
5. Call 5555(7777@SPH) to report situation, site, code location, evacuation
destination location & if H.E.A.T. (Hospital Evacuation Assistance Team)
assistance required
6. Notify receiving area of situation & identify meeting point to receive patients
7. Ensure all rooms are vacated & taped & tape corridor doors when leaving.
8. Take all keys (include med keys), copy of patient & staff census
9. On arrival, confirm head count & update Command Center of status & any
needs/issues
10. Assign staff to care for patients based on acuity; release other staff to return
to home base
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IF EMERGENCY REQUIRES EVACUATION OUTSIDE BUILDING:
Direct all area occupants to assemble outside in an orderly fashion away from
an exit or fire hydrant
Ensure everyone is accounted for & notify Command Center if someone is
missing
Assign a Runner to update Command Center
Instruct staff to remain with their groups, assess & comfort patients & await
further direction from Command Center to move patients to emergency
transport or external triage / transfer point.
Triage & identify critical patients for first available transfer;
Unless directed to do so, do not re-enter an affected area until the “All Clear” is
given.
On notification, Staff in Evacuating Area…
Assemble in area code staging location
Receive & complete assigned tasks & report updates to ACP
Prepare patients for evacuation
Remain calm, walk rapidly, but do NOT run. Reassure patients & visitors, & in a
calm manner quickly evacuate them from the area.
Keep movement on right side of corridors & stairwells to avoid blockage Check patient condition and emotional health periodically
When teams no longer needed, Area Charge Person will direct unit staff to the
evacuation destination to help care for evacuated patients & release other staff to
return to their home base.
Do not leave until released from duties by ACP
On arrival to destination area follow direction of receiving ACP or delegate
Area Charge Person in Receiving Area…
Put on vest & assemble staff & debrief
Organize staff to receive incoming patients, clear corridors/exits, rearrange
rooms/space
Staff in Receiving Area… Assemble in area code staging location Receive & complete tasks to make room for incoming patients (e.g. clear corridors/exits,
rearrange rooms/space)
Applies to: All HHS staff, affiliates & members of the medical & midwifery staff
1.0 Purpose: To outline the procedure to follow for a safe partial or total evacuation of a Hospital
area, wing or building.
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2.0 Code Green Definitions
Code Green Alert is announced when information indicates an evacuation is possible, but not
yet confirmed & additional investigation/information is needed for any response activation.
Code Green STAT is implemented when immediate evacuation of all persons from an area of
clear & present danger to one of safety is needed. It is activated only in situations that pose a
clear & immediate hazard to persons in the area.
Code Green is a precautionary & planned evacuation used for situations that may pose a
threat to persons, but allow time to prepare for evacuation. It is based on evacuation
directions from the established Command Center & has two stages: Code Green Standby which requires all staff to return to their work stations &
prepare their area for an eventual but definite evacuation. Code Green In Effect which activates implementation of a controlled evacuation of all
occupants in area(s) identified by the Command Center.
Code Green-All Clear identifies that all areas can resume normal duties. Those areas already
evacuated are to receive specific direction from the Incident Manager/Command Center
2.1 Code Green Notification can occur in various ways: Overhead announcement & page of a
Code Green STAT, Standby or In-Effect with or without the rapid ringing of the fire alarm
bells. The sounding of the evacuation fire alarm bells without additional notification by
overhead, paging, phone or Runner for a Code Green Standby or In-effect is considered a
Code Green Alert in the absence of clear & present danger signs. Staff will always be directed
or notified by the Command Center when to activate a Code Green (Precautionary) response.
2.1 Types of Evacuation
Horizontal Evacuation: entails evacuation of all persons on a floor to a place of safety beyond
2 fire/smoke barrier doors on the same level. It is the first evacuation response before vertical
evacuation is considered. Patient care areas should evacuate to another patient care area so
equipment & health care provider staff are readily available.
Vertical Evacuation: When horizontal evacuation is not possible, evacuation should then
occur vertically always towards ground level in anticipation that exit from the building may be
required. Move patients either 2 levels at a time towards ground level or directly to ground
level exit. If possible, evacuate from the side of the building not affected by the emergency or
used by emergency personnel. Ambulatory patients should proceed down stairwells first,
followed by transport of non-ambulatory patients, applying “keep to the right” rule & using
appropriate lift & carry techniques (see Appendix). Staff should be posted at all stairwell &
exit points to coordinate movement, restrict access & facilitate patient tracking.
TOTAL WING OR BUILDING EVACUATION: ENTAILS
EVACUATING THE WING OR BUILDING IN A CONTROLLED & COORDINATED MANNER DIRECTED BY THE COMMAND CENTER/INCIDENT MANAGER.
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Evacuation Routes: Each area should have two horizontal evacuation routes, one primary &
one secondary route. Primary & secondary evacuation routes should always be in opposite
direction of each other. In some cases, a secondary route may entail traveling down a
stairwell to the outside of the building & re-entry into a safe area.
2.2 General Principles for CODE GREEN (PRECAUTIONARY/PLANNED) EVACUATION • A Command Center delegate will direct the Area Charge Person when to initiate evacuation
(code green in-effect) of the area & the evacuation destination. However, if at any point
the situation changes & safety becomes an issue, the Area Charge Person may implement
a STAT Evacuation of their area. • Only on Command Center direction should staff fan-out or patient decanting (patient
discharge/transfer) processes be initiated; • If evacuation is not immediate & beds are required, patients to be discharged may be
placed in waiting areas in the pt. care are, with continued meals & meds provided until
they are transferred to the Discharge Holding Center (if established) 30-60 minutes before
scheduled pickup; • Ambulance dispatch communication will be coordinated centrally through the Site
Command Center. • In a code green standby, all patients are returned to their home unit if possible. If an
operation or procedure cannot be interrupted, it may be continued at the discretion of the
medical staff person in charge & the home unit notified that the procedure area will take
responsibility for evacuating the patient & relevant documents (chart, kardex, Medication
Admin Record) as needed. 2.3
Authorization for Evacuation & Re-entry
• Evacuation of part or all of the Hospital building is only initiated by a clear & immediate
threat to injury or loss of life following consultation with relevant parties (e.g. Fire, Police). • The decision to evacuate an area in immediate danger is with the area’s Charge Person. • The decision to activate a coordinated, planned evacuation of an entire floor, wing or
building evacuate the entire building is with the Incident Manager of the established
Command Center, who directs the evacuation process & specifies which areas are to
evacuate when & to where. The Incident Manager, in consultation with the appropriate
personnel (e.g. Engineering, Security, Fire, Police), also determines if re-entry is safe &
permits re-entry or identifies other plans.
2.4 Responsibilities
All staff are reminded that in the event of an evacuation, their assistance may be needed to aid in the movement of patients, based on their knowledge & physical capability.
2.5 Order of Evacuation
Evacuation of all occupants is a priority & judgement must be exercised to determine the order
to undertake the tasks involved given the time available & safety involved..
Area specific evacuation is first to a safe assembly area near an exit & as far as possible from
the hazard on the same level. Patients are evacuated horizontally through at least two corridor
fire/smoke barrier doors away from the hazard on the same floor. Once in the safe area, the
evacuation routes & direction of the charge person of that area are to be followed. Horizontal
evacuation can be self-initiated if there is a clear & present danger.
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Planned Patient Evacuation Triage & Discharge Evacuation triage divides patients based on mobility (i.e. ambulatory, wheelchair & bedridden)
& what further care is required (e.g. discharge home +/- CCAC or transfer to other facilities).
Transportation needs are determined as: next of kin car pick-up, bus/DARTS drop-off service or
ambulance. Critical cases needing immediate & constant treatment are transferred first by
ambulance from the ED. Stable stretcher patients needing further care can await transfer via
ambulance in a designated area (e.g. parking lot). Discharged patients are escorted to an
identified Discharge Holding Centre for pick-up by their next of kin. This information is
documented individually & then collated & submitted via the online Code Patient Evacuation
Summary Report for review & direction by the Command Center.
2.6 Interim Staging Location or Meeting Point In evacuation, patient care areas can bring their patients & visitors to a predefined interim
staging location or midway meeting point where patients are passed to receiving area staff who
continue to move the patients to their evacuation destination. However patients & staff in an
immediate crisis area may evacuate directly to their evacuation destination if their Area Charge
Person deems it to be more expedient. The Area Charge Person will identify staff who are to
remain with patients in the new location & those who are to return to help with further
evacuation.
2.7 Elevator Use
• Elevators are only to be used if permitted & manually operated by authorized staff. • When elevator use is permitted, the flow & sequence of elevator evacuation is different i.e.
bedridden patients are moved first, then hose requiring wheelchairs & finally ambulatory
patients. Patients evacuated first should be moved to the farthest location to minimize
congestion. • When elevators are not permitted or not functional, first escort ambulatory patients, then
wheelchair & finally evacuate bedridden patients by whatever means possible (e.g.
Evacusled, blanket drag etc…)
2.8 Continuity of Patient Care & Transfer of Information
In a total planned building evacuation, charts, kardexes & medication administration records are
sent with the patient on transfer to another facility or retained by the designated HHS staff for
discharged patients. A log (in duplicate) of the patient’s name, unit, Most Responsible Physician
& destination is completed at exit from the Hospital by assigned clerical staff. Patients
transferred or discharged will be called back to Hospital as necessary. Admitting staff will update
patient location records on receipt of information & contact patients’ next of kin to inform them
of any facility transfer.
In a planned total building evacuation, time permitting, a Transfer Form (in duplicate) with
patient’s diagnosis & treatment requirements should accompany patients with their health
record, care plan, kardex & medication administration record. Admitting staff will use the copy
to confirm patient arrival at destination.
A tag can be used for any patient needing special handling e.g. patients needing meds within
next 4 hours. The tag should include the time the med is due & is removed after it is given &
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no further medication required. Whenever possible patients’ medications should accompany
patient.
2.9 Equipment Patient beds or equipment are only moved if the patient’s condition requires it. Incubation,
isolettes & other life support systems are moved with the patient if possible. Respiratory Therapy
staff & Porters will transport ventilators & monitoring equipment & ensure they are labeled.
2.10 Visitors
The Command Center will determine if visitors are asked to leave the hospital or remain to
reassure & assist patients during evacuation. This based on the reason for evacuation & safety
issues.
2.11 H.E.A.T. (Hospital Evacuation Assistance Team)
An area evacuating is to identify any need for additional staffing to assist with the evacuation.
This is based on the patient population mobility status, the area’s staffing complement & the
urgency of evacuation. If immediate assistance is critical, the Area Charge Person is to request
Switchboard to announce activation of H.E.A.T. (Hospital Evacuation Assistance Team) & the
area in need.
On hearing the announcement all clinical & non-clinical areas are to deploy one staff member to
the evacuating unit & report to the Area Charge Person there for appropriate assignment. Once
there, staff are to remain on the unit completing assigned tasks until released by the Area
Charge Person.
Staff Deployment Center
In a code green (precautionary) required & available staffing assistance is submitted via
the online Code Resource Status Report. If there is time, a staff deployment center is
activated & the location announced (e.g. cafeteria). When Telecommunications
announces the location of an established Staff Deployment Center, staff who do not have
direct clinical patient care responsibilities & those who have completed their patient care
responsibilities (e.g. outpatient areas) are to report to the designated deployment
location, after securing their area, to be assigned to assist with the evacuation process.
2.12 Area Specific Information for Code Green includes: a) Occupant Tracking Record used (e.g. Staff Attendance Lists or Sign In Sheets; Census or
Clinic record for Patients & Visitors)
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b) Horizontal Evacuation Destination & Interim Meeting Point (for in-pt areas only) e.g.
midway between 2 areas c) Floor plan with primary & secondary horizontal & vertical evacuation routes & exits d)
External Assembly Area
Equipment needed: 2” Masking Tape; Flashlight with batteries; knife/scissors
3.0 Procedure- see Flowchart & Action Checklist
4.0 Developed By Code Green Subcommittee
5.0 Approved By Sr. Management, MAC, PAC, EDM Steering Committee
Lift & Carry Techniques
Use correct lift & carry techniques to ensure proper spine alignment & prevent injury (Keep
Ears over Shoulders & Shoulders over Hips) with available evacuation equipment (e.g.
Weevacs, Evacusleds, Evacu chairs, Stairwell slides) & the following techniques as needed.
Note: This poster is placed in a
visible location by every bed that
has an Evacusled for quick
emergency reference.
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Side-By-Side (semi-ambulatory)
Stand beside pt
Secure pt’s arm around rescuer & hold pt’s wrist or hand if possible
Snug pt close
Walk to a safe area
Grasp the patient’s other
arm if possible
Bear Hug (semi-ambulatory)
Stand behind the person
Place arms under the person’s
armpits
Rescuer’s head should be kept off
to one side
Grasp person’s left and right wrists
Cross the arms in front
Gently prod the person to walk to a
safe area
Cradle Drop (non-ambulatory)
1. Ensure bed wheels locked or move bed against wall & put bed to lowest position
2. Place 2 blankets on floor partially under bed & past head of pt
1. Kneel beside bed with one leg raised closest to pt’s head
2. Grip pt under knees & shoulders 3. Lean back, sliding pt off bed
Cradle Drop (cont’d)
Control pt’s descent onto your lap & then onto floor while protecting head
Do not resist it
Fold blanket around pt Drag pt head first to safe area
Swing Carry (non-ambulatory) Needs 2 rescuers; can be used on stairs
1 st rescuer raises pt to sitting position 2 nd rescuer moves pt’s legs over side of bed One rescuer maintains control of pt at all times to
prevent pt falling to floor
Rescuers sit on each side of pt Pt’s arms placed on rescuer’s shoulders Rescuers secure their arm around pt’s back &
grasp each other’s arm Rescuers pass other hand under patient’s knees
locking hands or wrists
Swing Carry (cont’d) Extremity Carry (non-ambulatory) Needs 2 rescuers; can be used on
stairs
1. Standing between pt’s, 1st rescuer grasps pt’s legs just above ankles or under knees
2. 2 nd rescuer places their arms under pt’s arms & clasps their hands on pt’s chest
3. Both rescuers holding pt firmly lift pt simultaneously & move to safe area
Simultaneously lift pt & move to safe area ) Lowering Technique (
Lower pt to sitting position by kneeling down with leg closest to pt Lower pt from sitting position to lying position while protecting head
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Appendix B
Voice Communication and Building Automation Systems:
As a standard all overhead public announcements will be broadcast via Paging through
Telecommunications at ext. 5555. In the event that Paging is unavailable all systems (alarm,
voice communication and building automation), operational instruction are posted within the
CACF. To augment posted instruction, during a Code Red Fire Alarm the CACF and/or Central
Control Centre are manned by systems trained HHS Electrical Staff to ensure that any required
operational need is conducted in an expedient manner.
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DURING ANY SHUTDOWN OF FIREFIGHTERS’ ELEVATORS, THE PERSON IN CHARGE
WILL NOTIFY ALL SUPERVISOR STAFF. IF THE FIREFIGHTERS’ ELEVATOR IS NOT
OPERATIONAL FOR MORE THAN 24 HOURS, NOTIFY THE FIRE DEPARTMENT BY
CALLING 905-546-3333, OPTION 6 AND NOTIFY ALL OCCUPANTS BY POSTING
ANNOUNCEMENTS OF THE SHUTDOWN ON ALL FLOORS AT THE FIREFIGHTERS’
ELEVATOR. ALSO, THE PERSON IN CHARGE SHALL NOTIFY THE FIRE DEPARTMENT
AND ALL OCCUPANTS WHEN FIREFIGHTERS’ ELEVATOR HAS BEEN RESTORED
Appendix C
3G Child and Youth Mental Health Program (Inpatient Unit, Mental Health Assessment Unit
The 3G Child and Youth Mental Health Programs at McMaster Children’s Hospital include a
locked 22 bed in patient unit, 6 day hospitals spots, a Regional Program and staffing for the
Child and Youth Mental Health Assessment Unit (MAU) in the Emergency Department. Due to
the acuity of the patients (in the locked unit), when the fire alarm is activated Patients are
brought into one of the two lounges (Pts in rooms 7-22 in the North lounge, pts in room 1-6 in the south lounge). The
bedrooms/bathrooms/interview rooms are all checked and when confirmed empty the room is
locked and a piece of tape is put over the door jamb to identify rooms that have been searched.
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If the evacuation is required 3G will evacuate horizontally to room 3E26 yellow quadrant (multiple
pathways of egress to route to 3E26 available). If external evacuation is required the programs
will assemble in the main lounge (south lounge if the main lounge is not accessible) evacuate
through the purple section stairwell, assemble in the back garden and then proceed as a group
into the adjacent University Building
The Unit has specialized key activated pull stations with two keyways.
• One key will activate the first and second stag alarm
• The keyway on the left, labeled “pre-signal” will activate a stage one alarm and also unlock
the door directly adjacent to the activated pull station. Activating the pre-signal keyway at
the pull station by the front door will release ONLY the front entrance door. All other doors
will remain locked. • In the event that a stage one alarm needs to be called but more than one door is required
to be unlocked, more than one pull station may be activated to correspondingly unlock
numerous doors. • The unlocked door will remain disengaged as long as the key is turned to the “on” position
and until engineering resets the locks. • The keyway on the right, labeled “general alarm” will activate a stage two alarm and unlock
All Unit Doors • All doors will remain unlocked until the doors are re-engaged by security/engineering
All staff will have a pull station key in their possession at all times
Security will escort the Fire Department to 3G with keys.
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CAF (Central Animal Facility – 1U) controlled access area The CAF follows the standard HHS
Code Red Emergency Response Protocols. All Secured doors will release if the alarm point is located
within the Facility or within the CAF Quadrant - Red/Yellow quadrant. All doors are also automatically
released in a Stage Two Alarm. All Fire pull stations are of standard design and operation. All Exit doors
are clearly signed “Emergency Exit Door Released by Fire Alarm”.
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Appendix D
Code Brown
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YesNo
Staff activate Code Brown i.e.
q Remove occupants from spill area
q If safe & able, identify & contain spill
q Secure & restrict access to spill area with tape
q Call x5555 (x7777@SPH)(x400@WLMH), state site,
location, Code Brown & spill type i.e. chemical, biomedical-blood/cytotoxic or radioactive; spill location (area, room #). Leave name & ext. for additional contact
q Notify Area Charge Person who informs Manager/Supervisor
q Obtain & review Material Safety Data Sheet
q Wait for direction from IM based on spill type (see below)
Telecommunications
q Announces code brown & location overhead x3
q Contacts those on notification list based on spill type
q Notifies others as directed by Incident Manager
q Updates those involved in spill response of code status
Engineering if directed by IM...
q Shut ventilation or switch to total exhaust for
spill area
q Shut mechanical/electrical systems
q Respond to spill location to assist once air
handling system controlled
IM HSW for
chemical or
unkown spills
IM IP&C
for biomedical
(blood) spills
IM Pharmacy
for cytotoxic
spills
Code Brown “All Clear” paged
Code Green Standby or In-Effect announced & paged
q Staff do not call Code but
proceed with spill clean-up* & appropriately dispose of waste
q Complete & forward
Safety Occurrence Report* Dept causing spill is responsible for
actual spill clean-up regardless of location
Legend:IM= Incident ManagerIP&C= Infection Prevention & Control MOE= Ministry of EnvironmentHSW= Health Safety Wellness
Manager/Supervisor of Spill Area
q Ensure exposed staff, pts & visitors are
escorted to receive medical attention, Complete occurrence report & forward to relevant parties incl. EDM
q Arrange for incident stress management
for those involved as needed
q Ensure completion of any follow-up
activities e.g occurrence report; debriefing meeting
Security
q Respond to spill location
q Ensure area secured
q Meet & escort external spill
response company, if notified, to spill area
Incident Manager (IM)-HSW, IP&C, Pharmacy or Radiation Safety Officer...
q Act as Incident Manager or assume joint command with Site Director/Director on-Call or delegate
q Phone affected area to determine: nature & volume of spill, affected persons, potential hazards to life,
environment & property, if internal clean-up can proceed with direction or if external spill company required for clean-up (if latter, collaboration with Director/VP on-Call needed)
q Direct Telecomm to notify/update others as needed
q Review management of spill and requests follow-up as needed
q Advise Telecomm of “all clear” or Code Green status
Customer Support Service (CSS)notified only after spill
cleaned & safe for final rinse
HHS Code Brown Summary Checklist
IM Radiation
Safety Officer for radioactive
spills
or
Waste Management Coordinator notified if spill enters natural environment (e.g.
sewers, soil) for MOE & City notification
Staff observes or discovers hazardous material spill...
q has knowledge, skills & equipment to correct spill
situation safely
q able to handle size of spill
Staff discovers spill of
unknown or suspected
hazardous material in
an unstaffed area
Note:External spill company is
Quantum Murray @ 1-877-378-7745)
Note:Site Director/Director On Call to report spill to Ministry of Environment and City of Hamilton when WMC is out of office.
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1.0 Purpose
To define the response for an internal hazardous material spill that staff are unable to manage safely
in so as to protect the health & safety of patients, staff & visitors & to mitigate any adverse impact on
the facility or surrounding environment.
2.0 Equipment
Caution/masking tape & area specific spill kit (if applicable)
Appropriate PPE based on the hazard
3.1 Policy
The main purpose of the provincial WHMIS legislation is to require employers to obtain health and
safety information about hazardous materials in the workplace and to pass this information on to
workers. While most spills are handled without the need for external assistance, HHS recognizes that
not all spills can be safely cleaned up without additional advice, equipment or external assistance.
3.2 Code Activation
Staff are to call a code brown when they do not feel they have the knowledge, skills or equipment
necessary to correct a hazardous material spill (i.e. Chemical, Biomedical/Blood, Cytotoxic or Radiation
spill) safely or if staff cannot handle the size or nature of the spill. This includes a spill discovered in an
un-staffed area or any uncontained cytotoxic spill that occurs in the Chemo Suite/Pharmacy at the JCC
that cannot be covered with one chemotherapy prep pad (25cmx30 cm). See Addendum-JCC Chemo Suite
Use of Ventilation Switch in Code Brown.
3.3 Code Notification
Code Brown is paged overhead to ensure staff avoid the code area and via pager to the appropriate
areas for response i.e. HSW for chemical spills, Infection Prevention & Control for biomedical/blood
spills, Pharmacy for cytotoxic spills & Nuclear Medicine Radiation Safety Officer for radiation spills.
3.4 Payment for External Spill Response Company
As the department or program responsible for the cause of the spill is responsible for clean-up, they
are also accountable for costs associated with spill clean-up in the event an external spill response
agency is called.
3.5 Blood Spills
A large blood spill that cannot be easily contained & cleaned by staff at the scene should be
designated as a Code Brown. This applies to blood only.
3.6 Area Managers/Supervisors are responsible to ensure
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a) Code brown & spill education is provided to staff on hire with annual review & testing; area staff are trained to respond in an appropriate & safe manner with the necessary spill clean-up equipment including the appropriate PPE to be worn based on the hazard; training for flammable materials is provided every six months; code brown & spill education is recorded & kept for two years.
b) Hazardous materials inventory is completed & Material Safety Data Sheet (MSDS) information is available & current
c) All hazardous materials within their area have specific response procedures, which may include, but not be limited to MSDS
d) Availability of spill clean-up equipment & supplies (if applicable) with regular monitoring & replenishment after use
e) Exposed staff are escorted to receive medical attention and a Safety Occurrence Report is completed for any hazardous spill (Code Brown & non-code Brown) with notification to all applicable areas e.g. HSW, EDM, Waste Management Coordinator etc.
f) Prompt investigation & determination of root cause of spill with corrective/preventive actions implemented;
g) Debriefing meeting occurs within an appropriate period of time & includes all relevant parties h) Include location of area spill kit (if applicable) on HHS Area Specific Code Information Record
located in the area’s Emergency Preparedness Binder.
3.7 Staff are responsible to
take part in annual education, training and exercise/testing related to hazardous material spill management, WHMIS and Code Brown;
locate & know how to use spill clean-up equipment & supplies in their area/unit; know when to call a code brown; complete a Safety Occurrence Report for any hazardous spill exposure participate in completion of the Safety Occurrence Report, investigation & root cause analysis for
the spill event.
3.8 Incident Manager (i.e. HSW, IPAC, Pharmacy or NM Radiation Safety Officer) is responsible to
respond to Code Brown pages 24/7
provide direction & consultation to all stakeholders (i.e. Engineering, CSS etc…)for the overall management of the spill clean-up
determine “all clear” notification
ensure a debriefing meeting is scheduled within an appropriate period of time, facilitate the process & summarize the debriefing meeting in the Safety Occurrence Report.
4.0 Procedure- See HHS Code Brown Summary Checklist on page 1
5.0 Definitions
Spill: Any unplanned or uncontrolled release of any hazardous material (biomedical, cytotoxic,
chemical or radioactive) that can pose a potential safety or health risk to people or the
environment.
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Reportable Spill to the Ministry of Environment (MOE) is a discharge of a pollutant that causes or is
likely to cause an adverse effect and encompasses all of the following circumstances:
into the natural environment from or out of a structure, vehicle or other container that, in quality or quantity, is abnormal in light of all the circumstances of the discharge The Waste Management Coordinator or designate is to be contacted to notify the MOE & City of
Hamilton Spills Center-see Appendix
6.0 Cross References
Biomedical Waste Disposal Protocol
NM- Emergency Radioactive Spill Response, Investigations & Reporting
Cytotoxic Agents: Safe Handling Policy-Segregation, Preparation, Transportation & Waste Disposal
Mercury Spill Procedure
Spill Response Protocol
Workplace Hazardous Material Information System (WHMIS) Procedure
MAC-Occurrence Reporting and Management Protocol
Addendum- JCC Chemo Suite Use of Ventilation Switch in Code Brown
7.0 Developed By, In Consultation With:
CSS Waste Management; Emergency Disaster Management; Infection Prevention & Control; Health,
Safety & Wellness; Joint Health & Safety Committees; Pharmacy
8.0 Approved By EDM Steering Committee
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SPILL CONTROL PROCEDURES
IN CASE OF SPILL
A) DETERMINE THE TYPE OF SPILL, IS IT A MINOR OR A MAJOR SPILL?
Definitions: - Minor spill – A minor spill is small enough that it can be safely cleaned up using the spill kit
- Major Spill – is one that cannot be contained safely with the materials on the site and or
threatens to enter the sewer system or travel beyond the boundaries of the plant to endanger
the environment.
B) IMMEDIATELY ACTIVE A CODE BROWN IF ANY SPILL (MAJOR OR MINOR)
OCCURRED
Call 5555 state: site, location, Code Brown and Spill type i.e. Flammable liquid.
Wait for directions from Incident Manager
C) CONTAIN AND CLEAN UP THE SPILL, BY QUICKLY SHUTTING OFF THE SOURCE IF
POSSIBLE. IF THE SPILL IN MINOR, USE ALL NECESSARY ITEMS LOCATED IN THE
SPILL KIT TO CONTROL, AND CLEAN UP THE SPILL. IF THE SPILL IS MAJOR FOLLOW
THE INSTRUCTIONS PROVIDED BY THE INCIDENT MANAGER.
D) CONTROL ANY IGNITION SOURCES. THE SPILL SHOULD BE ISOLATED FROM ANY
POSSIBLE IGNITION SOURCES SUCH AS SMOKING, WELDING ELECTRICAL
EQUIOPMENT AND GRINDING.
E) INITIATE VENTILATION MEASURES. VENTILATE THE AREA TO PREVENT VAPOURS
FROM SETTLING ON THE FLOOR, IN PITS STAIRWELLS AND TRENCHES OR OTHER
AREAS BELOW THE FLOOR LEVEL
F) IN CASE OF FIRE CALL 5555 FOLLOW THE CODE RED SAFETY PLAN.
G) ARRANGE FOR THE DISPOSAL OF WASTE MATERIAL IN ACCORDANCE WITH THE
MINISTRY OF ENVIRONMENT AND ENERGY REQUIREMENTS.
External Spill Company is Quantum Murray 1-877-378-7745
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All employees involved in the handling, use and storage of flammable and combustible
liquids are required to know the hazard associated with these liquid. The Emergency Spill
Incident Manager shall be responsible for ensuring this data is available to employees and
that Material Safety Data sheet are updated when any new materials is brought into the
facility or a new material is produced.
Personnel should be trained both in prevention and responding to an incident in order to
create a risk awareness among the employees. All personnel should have practical
training in alarm procedures, lifesaving, and the reduction of environmental damages and
on the proper method of handling a minor spill using the emergency spill kit.
Proper protective clothing and equipment outlined in the Material Safety Data Sheets shall
be provided in the spill kit and shall be tailored to the particular facility (i.e. rubber gloves,
rubber boots, self-contained breathing apparatus etc.) This spill kit shall be checked
regularly and inspected after every use.
A preventative maintenance program shall be implemented, including training of new staff
within three months of being hired and for experienced staff every six months.
Mechanical protection will be provided for all vessels carrying flammable or combustible
liquids to prevent spills and leaks.
A COPY OF THIS PLAN SHALL BE POSTED IN ALL AREAS THAT HANDLE, STORE OR
USE FLAMMABLE AND COMBUSTIBLE LIQUIDS.
Appendix – E
Fire Site Plan
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