Download fire and evacuation plan

Hospital
Patient Care Areas
FIRE AND
Relocation /
Evacuation PLAN
UNIVERSITY OF CALIFORNIA
DAVIS
Main Hospital
2315 Stockton Blvd
Sacramento, CA 95817
*Please fill out the highlighted areas as applicable for your individual unit or area. Please be sure to thoroughly
read the plan as it has been substantially updated. Upon completion, please save a copy for yourself and submit
an electronic copy to Melissa Vink with UCDHS Fire Prevention at [email protected] for review.
Once reviewed, the Fire Prevention Department will send the final version back to you and maintain a copy in
our files.
HOSPITAL (Patient Care) UNIT / AREA NAME: ________________
This Fire and Relocation / Evacuation Plan is to be used by staff* to protect visitors and
themselves from fire or other emergencies requiring evacuation from the building. In
conjunction with the fire evacuation signs posted throughout the building, this plan
satisfies the requirements of Section 3.09 of the California State Fire Marshal’s
Regulations and meets the requirements of The Joint Commission.
* Staff includes all UC Davis Health System employees, faculty, licensed independent
practitioners, contract workers, etc.
Report all fires, even if fire is immediately contained.
Dial 911 from a landline or 734-2555 from a cellular phone.
AREA SPECIFIC FIRE PROTECTION COMPONENTS
This section is filled in by UCDHS Fire Prevention Department
Fire Component
Area is constructed of non-combustible structural materials, principally
concrete and steel.
Yes
X
Corridor doors should be in the closed position during a fire emergency.
X
Automatic Fire Sprinklers are installed in area.
Fully sprinklered
Partially sprinklered; Define areas with sprinklers:
______________________________________________________
Smoke Detectors are installed in the area.
Manually activated red fire alarm pull stations are located in the exit routes
of this area.
Audible fire signal installed in building.
Type = (fill in) ______________________
e.g. Chime, automatic voice message
Visual fire signal (e.g. strobe lights) installed in area.
Fire Extinguishers in area.
A / B / C Type (for use on most fires)
Other (fill in) __________; for use on (fill in)__________________
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No
HOSPITAL (Patient Care) UNIT / AREA NAME: ________________
Familiarization
Become familiar with the floor plan for the area and know the locations of:
 Manual Pull Stations (MPS), fire extinguishers, and telephones
 Exit routes and exit doors.
 Adjacent smoke compartments.
TRAINING
The Fire and Relocation/Evacuation Plan consists of two essential elements,
both of which must be present for it to succeed:
1. Written guidelines & posted information - The plan contains general
information applicable to the entire building, as well as specific guidelines and
floor plans for each clinic within the building. Fire evacuation signs located in
each building and near the exit stairwells are designed to complement the
plan.
2. Employee training - Your training is essential to the success of this plan.
Without training the fire plan will not work for you or your associates, so take
time to learn and practice the procedures on a regular basis.
GENERAL FIRE PROCEDURE
If a fire occurs, you should follow the R.A.C.E. procedure:
RACE-
RESCUE
ALARM
CONFINE
EXTINGUISH
Rescue

Rescue anyone (this includes yourself) who is in immediate danger from the
fire. Remove these people to the closest safe area, simultaneously notifying
other staff of the fire and its location. Know where alternate exits are
located.
Alarm

If you are the first person to discover a fire, communicate your discovery to
other staff in the area, activate the closest fire alarm activating device; call 9-11 from the nearest safe location. If you are involved in rescue, send
someone to call 9-1-1.
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HOSPITAL (Patient Care) UNIT / AREA NAME: ________________
Confine

Confine the fire by closing all of the doors in and around the fire area. This will
help keep fire and smoke from contaminating the exit paths during evacuation.
It also helps to keep the fire to a much smaller area and aids in preventing it
from spreading to other areas.
Extinguish

There is no better time to control and extinguish a fire than in its early stage.
Utilize fire extinguishers, acronym P.A.S.S., if you discover a fire in its earliest
stage. If a fire is well developed, however, the best thing to do is close the
doors around it and get out. Do not place yourself at unnecessary risk–your
greatest value is as a rescuer, not as a firefighter.
P-PULL
Stand back from the fire and pull the pin.
A-AIM
Aim the nozzle at the base of the flame
S-SQUEEZE Squeeze the handle
S-SWEEP Sweep the nozzle from side to side at the base of the flames
until the fire is completely extinguished.
The Sacramento Fire Department is responsible for extinguishing fires at the
Medical Center. You should never hesitate to call 9-1-1. Remember that a fire,
even a small fire, presents an extreme risk to patients and staff, so don’t
hesitate – act immediately!
As a Reminder:



All fires will require an investigation as to the cause.
A report must be taken by UCDHS Fire Prevention Department investigator after
each event.
Wait for an ALL CLEAR from UCDHS Fire Prevention or the Sacramento Fire
Department before re-occupying a building/area after a fire.
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HOSPITAL (Patient Care) UNIT / AREA NAME: ________________
Hospital Unit/Area RELOCATION / EVACUATION PROCEDURE
To be filled in by Unit or Area Manager
in consultation with UCDHS Fire Prevention
BUILDING ASSEMBLY AREA
Primary Relocation Site*:
Alternate Relocation Site:
Evacuation Staging Area

Pavilion Lobby or Tower Lobby

ED (for ICUs only)
* Relocation Site = Adjacent or other smoke compartment(s) identified for
relocation with adequate resources and utilities to manage patients.
Movement will begin with relocation of patients most affected by the
emergency in the following order:
1. Patients in immediate danger
2. Ambulatory patients
3. Non-ambulatory patients
Relocation/Evacuation Movement Priority:
1. Horizontal from the danger area to a safe area on the same level.
2. Vertical to a lower (or higher) floor, as necessary
3. To the Staging Area(s) on first floor (Tower Lobby, Pavilion Lobby, or
Emergency Department) to prepare for evacuation to another facility;
only upon direction from Incident Commander.
If you are the first person to discover a fire or other emergency necessitating a
building evacuation, call 911 (from a landline) or 916-734-2555 (from a cellular
phone). Communicate your discovery to other staff in the area and activate the
closest fire alarm device. For response to criminal activities, refer to 1.a.
below. If you are involved in rescue, send someone to call 9-1-1.
a. For criminal activities, such as a bomb threat, active shooter, or
hostage situation, call 911 from a land line. Unless directed by
emergency responders (fire or police), do not activate the fire alarm
system.
i. For a bomb threat, turn off all two-way communication
devices, such as two-way radios, cell phones, and Vocera.
Code Green, Internal must be initiated for any incident that triggers the
relocation or evacuation of patients.
All Staff (including nurses and physicians) will take personal belongings, such
as purse or wallet, car keys, and cell phone, if items are immediately available.
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HOSPITAL (Patient Care) UNIT / AREA NAME: ________________
RELOCATION / EVACUATION PROCEDURE (for any unit/area with direct
patient care)
1.
Direct family and visitors to the nearest exit as they are to evacuate to the
outside of the building.
2.
If relocation is necessary, move patients and staff horizontally into adjacent
smoke compartments and close the smoke barrier doors to provide
separation from the emergency. Generally, in most emergency situations,
patients are held in the relocation site(s) until conditions stabilize.
3.
Group patients according to ambulatory status. Assign personnel to move
specific groups. Patients will be relocated to the Relocation Site in the
following order - unless otherwise notified by the Incident Commander or
the Sacramento City Fire Department.
3.1
Patients in immediate danger
3.2
Ambulatory patients (moved in small groups by staff).
3.3
Non-ambulatory patients who do not require life support equipment
3.4
Non-ambulatory patients who require life support equipment.
3.4.1 It may be necessary to move these patients to areas beyond
the nearest area of refuge to assure they have the appropriate
medical services warranted by their condition.
4.
Nursing staff and physicians will quickly assess the patient needs before
relocating / evacuating, items to consider include, but are not limited to:
4.1
Coordinate with Respiratory Therapy to transfer oxygen and/or
ventilator dependent patients to portable oxygen units. Bag patients
as needed on portable oxygen.
4.2
Turn off oxygen, air, suction, and flow meters at the wall.
4.3
Disconnect/discontinue
(monitors).
4.4
If patient on dialysis, disconnect, clamp and tape dialysis lines with
assistance from Dialysis Nurse
4.5
Send infusion pumps and/or feeding pumps with the patients, if
possible.
4.6
Place belongings in the clothing bag with the patient's name and
medical record number. Place all Patient's medications (including IVs
and IV medications), prosthetics and special patient need items in a
labeled bag inside the clothing bag.
non-essential
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equipment
from
patient
HOSPITAL (Patient Care) UNIT / AREA NAME: ________________
5.
If the entire unit is to be vacated,
5.1
Shut off oxygen zone valves.
5.2
Take the crash cart and portable defibrillator with the patients to the
safe area, if safe to do so.
5.2
Shut off oxygen zone valves.
6.
Pediatric
/
Infant
/
Intensive
Care
Nurseries
will
move
infants/toddlers/children by carrying them or by using isolettes, warmers,
bassinets, cribs, blankets, or staff may use the kangaroo aprons, such as
“Safe Babies Apron”, where available.
7.
Non-ambulatory patients will be moved using beds, stretchers, wheelchairs
or litters.
8.
VERTICAL: When vertical relocation is required, patients must be moved
to different floors or to the first floor. Vertical relocation must be
accomplished in the following order:
8.1.
Elevators - Elevators may be used. If smoke is detected in any
elevator lobby on any floor, the elevators will automatically proceed
to the first floor and will remain out of service with the doors open
until overridden by the Sacramento Fire Department or UCDHS Fire
Prevention. Elevators that serve the fire area are generally held for
Fire Department use. The elevators in other building wings,
however, are separated by smoke compartment walls and should be
used under the direction of the AOD, Nursing Supervisor, or other
emergency response personnel.
8.2
Ramps may be used for vertical relocation. The ramps are accessed
from the North-South wing.
8.3.
Stairwells - if patients cannot be moved horizontally to locations
where there is an operational or safe elevator, move them vertically
using the exit stairwells. Transport non-ambulatory/critical patients
using vertical evacuation equipment (i.e., ParaSlyde or evacuation
chairs are available on Davis 10, 11, 12, and 14). In an emergency,
it may be necessary to improvise with available equipment. Where
no other method is available, use a two-person or three-person
carry.
8.4
If an individual cannot be moved vertically using the stairwells, they
are safest left in their room with the door closed. Immediately report
the name and location (floor and room number) of the person to the
fire department/ emergency responder.
8.5
<<Delete 8.5 and 8.6 text if not applicable to unit>> Patients in
Davis Tower floors 10 to 14 cannot be relocated horizontally to the
University Tower or East Wing; if the entire floor must be vacated,
patients must be moved vertically to a lower floor.
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HOSPITAL (Patient Care) UNIT / AREA NAME: ________________
8.6
Assign personnel to relocate specific groups. Patients will be
relocated to the pre-identified Relocation Site(s) unless otherwise
notified by the Incident Commander.
8.6.1 Davis Tower 10 (PICU) evacuate to
(identify
possible areas in Pavilion (ie PACU), or University Tower /
East Wing on floors 6, 7, 8)
8.6.2 Davis Tower 11 evacuate to
(identify
possible
areas in University Tower or East Wing on floors 6, 7, 8)
8.6.3 Davis Tower 12 evacuate to
(identify
possible
areas in University Tower or East Wing on floors 6, 7, 8)
8.6.4 Davis Tower 14 evacuate to
(identify
possible
areas University Tower or East Wing on floors 6, 7, 8)
8.7
Non-ambulatory patients will be evacuated using ParaSlydes,
Stryker Chairs, beds, wheelchairs or litters.
8.7.1 Evacuation equipment, including ParaSlydes, is located in
Room 14776 on Davis 14, Room 12776 on Davis 12, Room
11776 on Davis 11, and Room TBD on Davis 10.
8.7.2 Instructions for use of ParaSlydes are located in outer pocket
of storage bags.
9
To prevent duplication of efforts during the evacuation, staff should apply
tape across the door and door jam to indicate that the room has been
evacuated.
10.
Once patients are taken to the Relocation Site(s), the Incident Commander
will coordinate the placement of patients into new areas with the assistance
of Administration and Bed Control, as needed.
11
When Incident Commander, UCDHS Fire Prevention, or the Sacramento
City Fire Department declares the evacuated area to be safe and free from
any hazards, the Incident Commander will coordinate re-occupancy of the
unit(s).
12.
If patients need to be evacuated to other facilities, the Memorandum of
Understanding for Patient Transfers will be implemented. Patient transfers
to other facilities will be coordinated by the Incident Commander.
13
For evacuation of an entire wing or the whole facility, complete Attachment
2 to provide transportation requirements for patients in the unit to the
Hospital Command Center and move patients to the Staging Area.
a. Ambulatory patients should be moved to the Tower Lobby or Pavilion
Lobby (as directed by the Incident Commander) for transport by bus,
van or other multiple-passenger vehicle
b. Non-ambulatory/critical patients should be moved to areas near the
Emergency Department (ED) entrance for transport via ambulance
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HOSPITAL (Patient Care) UNIT / AREA NAME: ________________
c. Print the patient’s medical records to send with them. At a minimum, the
“Snap Shot” and “Demographics” information in EMR will be printed plus
other information, as needed. If EMR is not available, the pertinent
information will be written on the Transfer Record.
d. Fill in HICS Form 260 “Patient Evacuation Tracking Form and make
copy. Send one copy with patient and keep one copy for records.
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HOSPITAL (Patient Care) UNIT / AREA NAME: ________________
Area-Specific Instructions: Copy or Delete this section, as applicable.
OPERATING ROOM AND POST ANESTHESIA CARE UNIT
Refer to (or copy) information in P&P 1637 -- or --- Copy and paste applicable text
into Relocation/Evacuation Procedure #4.
1.
Nursing staff and physicians will quickly assess the patient needs before
evacuating:
2.1
Move only those patients in immediate danger.
2.2
Obtain portable oxygen tanks for each room.
2.3
Surgeons need to effect hemostasis and cover open wounds appropriately
2.4
Transfer patient to gurney.
2.5
Transport portable equipment with patient as needed
2.6
Turn off oxygen zone valves.
EMERGENCY DEPARTMENT:
Copy and paste applicable text into Relocation/Evacuation Procedure #4.
1.
2.
If the Emergency Department must relocate or evacuate patients in the ED:
a.
Determine status of patients receiving treatment in the ED;
b.
Triage patients to determine suitability for discharge, relocation to another
location within the hospital, evacuation and/or transfer to on-site clinics for
interim care, or evacuation and transfer to another hospital. Use
attachment 2 to document patient type and transport needed for those
patients identified for transfer.
c.
Discharge as many patients as possible.
d.
Based on the level of relocation/evacuation required, either prepare the
patient for transfer to another facility or move the patient to a holding area
in the ED to await in-house admission.
e.
Assign all available staff to the relocation site to care for patients and/or
prepare patients for transfer to other facilities.
f.
Document actions and decisions on a continual basis.
For evacuation of an entire wing or the whole facility, the Emergency Department
will receive non-ambulatory/critical patients from the hospital units to prepare for
transfer to another facility via ambulance.
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HOSPITAL (Patient Care) UNIT / AREA NAME: ________________
++++++++
Additional Resources that may be requested for the relocation/evacuation of patients,
including:












Lift Team to assist with evacuating patients
Patient Transport to assist in evacuating patients
Other medical services (physicians and nursing) to assist in maintaining
emergency patient care
Respiratory Therapy Staff to assist with oxygen needs
Pharmacy (medications)
Clinical Engineering Staff to assist in obtaining additional equipment (such as
portable suction machines, IV Poles, Defibrillator, Cardiac Monitors, etc).
Linen (blankets)
Central Processing or Distribution (supplies)
Code Blue Team (if needed)
Trauma Team (if needed)
PO&M (special utility needs such as medical gas).
Blood Bank.
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HOSPITAL (Patient Care) UNIT / AREA NAME: ________________
COMMUNICATION PLAN
Hospital CONTACT LIST
To be filled in by Unit/Area Manager
Nursing Supervisor
Name
Pager Number
Nursing Supervisor
916-762-5364
Patient Care Resources
Name
Phone Number
Bed Control and Staffing Office (24/7)
734-7083
Name
Phone Number
E-mail Address
Relocation Site CONTACTS - if applicable
Relocation Site
Contact Name
Phone Number
Cell Phone
E-mail Address
Relocation Site
Contact Name
Phone Number
Cell Phone
E-mail Address
Relocation Site
Contact Name
Phone Number
Cell Phone
E-mail Address
Relocation Site
Contact Name
Phone Number
Cell Phone
E-mail Address
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HOSPITAL (Patient Care) UNIT / AREA NAME: ________________
DEPARTMENT CONTACT LIST
To be filled in by Unit/Area Manager
UNIT / AREA CONTACTS
Unit Name
Name
Phone Number
Cell Phone
E-mail Address
Unit Name
Name
Phone Number
Cell Phone
E-mail Address
Unit Name
Name
Phone Number
Cell Phone
E-mail Address
Unit Name
Name
Phone Number
Cell Phone
E-mail Address
Unit Name
Name
Phone Number
Cell Phone
E-mail Address
Page 13 of 14
HOSPITAL (Patient Care) UNIT / AREA NAME: ________________
SACRAMENTO CAMPUS EMERGENCY CONTACT INFORMATION
UC DAVIS FIRE PREVENTION
Phone Number – Front Desk
Phone Number - Emergency Only
Phone Number - Emergency Only
(916) 734-3036
911 (landline)
(916) 734-2555 (cellular phone)
UC DAVIS POLICE DEPARTMENT
Phone Number – Landline
Phone Number – Cellular Phone
911
(916) 734-2555
MEDICAL CENTER SAFETY (EH&S) CONTACT:
Name
Bob Lawson
Phone Number
(916) 734-2740 or (916)-734-3355
E-mail Address
[email protected]
MEDICAL CENTER EMERGENCY PREPAREDNESS CONTACT:
Name
Glynis Foulk
Phone Number
916-734-8261
E-mail Address
[email protected]
UCDMC UC DAVIS PARKING & TRANSPORT
Phone Number
(916) 734-8117
Pager Number
(916) 762-1230
UCDMC IT/TELECOMMUNICATION
Phone Number
Hospital Operator
(916) 734-8700
(916) 734-7020
UCDMC PATIENT ESCORT
Phone Number
(916) 703-4315
**************** Delete for Buildings with no Academic or Research Staff **************
SAC RESEARCH & ACADEMICS SAFETY (EH&S) & EP CONTACT:
Name
UC Davis Campus Safety Services
Phone Number
530-752-1493
SOM LABORATORY SAFETY OFFICER (DAVIS):
Name
Diane Hoffmann
Phone Number
(530) 304-0006 cell
E-mail Address
[email protected]
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