HEALTH-CARE FACILITY PREPLANS
A hospital emergency preplan can enlighten firefighters to the myriad of response concerns associated with a health-care facility. Some of these concerns include life safety for nonambulatory patients; patients in clinical areas; and laboratory, chemicalstorage, oxygen-storage, and hazardous-waste areas. It also acquaints fire personnel with the facility’s fire protection equipment. The New York Hospital/Cornell University Medical College (NYH/CUMC) complex internal preplan, discussed in this article, identifies for the first-due fire officers the locations of hazards that threaten life safety, as well as pertinent data needed by the incident commander.
The NYH/CUMC complex, which encompasses a three-square-block area on Manhattan’s Upper East Side, has 22 interconnecting structures, ranging from a 27-story high-rise building to subterranean tunnels. The suband sub-sub-basement tunnels connect with two other hospitals and several NYH/CUMC high-rise residential buildings. Because of the institution’s complexity, four internal preplan training sessions were conducted by the NYH/CUMC Safety Departments (one for the hospital and one for the university complex). Firefighters from New York City’s 10th Battalion attended each internal preplan session.
Each preplan session focused on responders’ concerns as they pertain to patient safety and locations of various hazards. Other preplan information covered fire protection equipment, laboratory safety, and NYH/ CUMC emergency plans.
A tour of the facility acquainted the firefighters, who formed two groups, with the complex’s layout. One group toured the university experimental laboratory area, while the other surveyed the hospital area. The tour enabled the firefighters to see the general layout of the buildings and to note the locations of elevators, stair shafts, and the Fire Command Center.
Changes in the buildings’ layout, construction, or facilities are relayed to the battalion chief of the responding fire department as they occur and are incorporated into blueprints and maps on file in the Fire Command Center, headquartered in the complex’s security headquarters in the Annex building. (It could be established in a hospital lobby or any other area designated by the health-care facility.)
We recommend that the fire department come in on an annual basis. The Joint Commission for the Accreditation of Hospitals (JCAHO) mandates that a minimum number of fire emergency drills be held during each building per quarter, and the fire department is invited to attend these drills, which are held during all personnel shifts. In addition, tours to familiarize personnel new to the local fire department with the NYH/CUMC complex are held every two years.
NYH/CUMC INTERNAL EMERGENCY PREPLAN
In the case of a real fire, w’hen the automatic fire alarm is transmitted to a central station, a direct call is made to the dispatcher of the local fire department to advise him/her that “we have a real fire” (they sometimes are called to the complex for false alarms and other incidents). The location of the fire is identified and the fire conditions described. (If the fire involves a laboratory, the city’s emergency hazardous-materials response also would be triggered.) Engineering and other department members of the complex’s Incipient Fire Brigade (an Occupational Safety and Health Administration [OSHA] term), a team made up of the complex’s employees from all job classifications, are assigned to meet the emergency responders at the entrance of the municipal trip location involved and direct them to the appropriate building. Teams of brigade members are dispatched to the incident floor and the floors above and below the fire to determine whether any immediate actions are needed before responders arrive. (At NYH/CUMC, brigade members are selected for these tasks by the fire safety engineer.) One such action might be to remove critical care patients who might be in the way of water coming down from the floor above. Depending on the extent and nature of the incident, triage would be established two floors below the incident site, and medical assistance and other specialized personnel would be on standby.
Incident command would be established at the complex’s Fire Command Center. The Command Center provides the incident commander access to an interior portable radio communication system; blueprints for facilities’ floor plans, HVAC systems, sprinkler/standpipe risers, electrical risers, and medical gas and other piping systems; tunnel areas; and material safety data sheets (MSDSs) for hazardous materials.
To further assist fire officers, relevant hospital data are transmitted to the company en route to the scene. The City of New York Fire Department computer dispatch is called “Critical Information Data System” (CIDS). Since the CIDS limits the information that can be relayed to 140 characters and the hospital has multiple buildings for each municipal trip address, our system, designated “CIDS/Extended Data” and available at the hospital’s Fire Command Center, gives details concerning hazards within the complex. These hazards include, but are not limited to, laboratories (the characteristics of each of the various classifications), hazardous-waste locations, chemical-storage rooms, mechanical systems, oxygen and therapeutic gas emergency shutoff valves, and X-ray rooms. Blueprints and maps of the floors and building systems also are included. Hazards are identified with regard to their exposure side of the building, sector area, and floor level.
Laboratory areas. Hospital laboratories present fire hazards not encountered in other health-care facilities. Fires or other emergencies involving these labs should be treated as hazardous-materials incidents, and all OSHA-mandated safety regulations should be followed. Water drains in these laboratories are made of glass, and the water is collected in an acidproof recapture tank and disposed of in accordance with appropriate mandated health and safety procedures.
Although laboratories rank fifth as the origin site of hospital fires, they have a very high fire load and present a great risk potential for rapid fires. The fire load may be a mixture of flammable liquids, compressed gases, toxic chemicals, corrosive irritants, unstable substances, biological hazards, and low-level radioactive materials. Laboratories basically are not concentrated in one area of the hospital, and some are located near patientcare areas. The potential fire risk factor in laboratories is due more to human error than to electrical or mechanical failure.
Laboratories encountered in hospitals are clinical labs within which specimens, blood, and body parts are analyzed and dissected. Some typical hospital labs are diagnostic labs that contain radioisotopes and surgicalpathology, tissue-preparation, and biohazard labs.
Some diagnostic labs use substantial amounts of radioactive materials. Federal and state regulations require that radiation exposure levels in these labs be well below the established regulatory limits. All spaces within which radiation materials are used or stored must be labeled with signs stating “Caution Radioactive Materials.” The greatest hazards in surgicalpathology labs, which are examination rooms, are biological. These labs examine potentially infectious organisms received from the operating rooms. Formaldehyde frequently is used on the tissue specimens, and the femes are especially irritating to the eyes and respiratory tract.
Tissue-preparation labs use highly flammable liquids and toxic solutions to process and stain specimens. Automatic tissue processors use melted paraffin and flammable liquids in the processing cycle. The processing machines should be located under an exhaust hood.
All patient specimens in biohazard labs must be considered contaminated. One of the ever-present dangers in these labs is that of being exposed to hepatitis B. Full protective gear should be used as a precaution when dealing with labs in health-care facilities.
All doors leading into a laboratory are labeled “Laboratory—Potentially Hazardous Substances.” Other signs are posted to indicate the fire hazard peculiar to the materials used within the lab.
Infectious diseases and toxic materials are among the health and safety hazards hospital laboratories pose for responders, in addition to those encountered in fires, explosions, and other incidents. Facility fire brigades and local firefighting personnel must be educated in the hazards they may encounter in these laboratories through appropriate signage of rooms, storage receptacles, exhaust hoods, and other areas that contain hazardous materials, and through briefings by hospital personnel.
Some nonflammable materials in a laboratory are stored in a refrigerator. Flammable materials must be stored in an explosionproof refrigerator; a label reading “Flammable Storage” is posted on the refrigerator door. The fume hoods found in labs pose additional safety concerns. Used to remove dust, fumes, gases, mist, and vapors and to prevent toxic exposures, the hoods are enclosed and have glass sliding panels in the front. These hoods are identified with big orange warning labels that have black print. The room air is drawn in at the lower level of the glass panel and the hazardous fumes are vented to the outside through a plenum.
Chemical storage areas. Large amounts of alcohol may be stored in pharmacy areas. Laboratories may have a designated chemical liquid and gas bulk storage room; these chemicals and therapeutic gases can be identified by container labels or colors. Some hazardous materials temporarily may be kept on the facility loading docks.
Oxygen and other therapeutic gases. Many hospitals rely on an exterior liquid oxygen bulk storage system. Lines piping in oxygen, nitrous oxide, nitrogen, and other medical gases are located throughout the hospital. All lines are labeled and color-coded. Emergency shutoff valves are labeled to indicate the rooms or areas they supply. Every patient area has an emergency shutoff valve located in the corridor space, and nurses are trained to shut off piped-in oxygen valves during an emergency. Maps of all piped-in lines, including those carrying waste water, are available in the Fire Command Center. A hospital also uses portable oxygen cylinders, located throughout the facility.
Radiation areas. Generally, X-ray machines that have been shut down do not present serious radiation hazards for responders during firefighting and salvaging operations. The primary concern during a fire is their high electrical energy.
Hazardous waste areas. Chemical, radioactive, and infectious waste materials are concentrated in separate, short-term bulk storage locations until they are appropriately processed for disposal. Infectious waste materials are red-bagged for disposal according to OSHA requirements.
BUILDING CONSTRUCTION AND FIRE PROTECTION EQUIPMENT
In addition to federal and local codes, minimum life-safety criteria governing new and existing hospitals are covered in NFPA 101, Code for Safety to Life from Fire in Buildings and Structures, 1991. JCAHO also has mandated life-safety policies and procedures that must be implemented by hospitals.
Compartmentation is a key component of the hospital’s fire protection system. Among mandated safety requirements pertaining to hospital construction are that smoke barrier doors be installed every 150 feet, that sensing devices be installed on smoke dampers of the HVAC system when fire walls are breached, and that there be at least two means of egress for each hospital wing. Corridors on patient floors must be eight feet wide, to accommodate all beds and provide room for maneuverability when it becomes necessary to evacuate nonambulatory patients. Totally enclosed self-latching doors must be installed on all stair towers, and the stair towers must be numbered as to floor level and identified numerically’ or alphabetically for the fire department. New York City requires alphabetical labeling.
The provisions of the Americans with Disabilities Act, signed into law July 26, 1990, also must be incorporated into hospital construction.
Health-care facility fire alarm systems are divided into multifire alarm zones. Structures interconnected by fire walls may have separate fire alarm zones, and multistory buildings may’ be divided into several vertical fire alarm zones. Whatever the case, an interior fire alarm must be transmitted to a central station. JCAHO requires that all hospitals perform a quarterly preventive maintenance test of their fire alarm system and log the tests.
The NYH/CUMC fire alarm system consists of 1,500 alarm devices. When an alarm sounds, a call automatically comes in to my office. The activated device is identified on a printer, and a graphic displays the activated device and its adjoining area, including features such as stairways and elevators.
Exterior Siamese connectors are color-coded to reflect appropriate connections. The universal code system is as follows: green/sprinkler system, red/standpipe, and yellow/combination sprinkler-standpipe system. An additional marker above each Siamese connection should indicate the standpipe riser locations and whether the building is partially or fully sprinklered. Appropriate signage should direct the firefighters to the hospital’s main fire pump and identify all valve locations.
Managing smoke movement is essential to patient safety, particularly in high-risk areas such as intensive care units (ICUs), operating rooms, and neonatal care and maternity wards. Fire department preplans must address the locations of ventilation ducts, smoke dampers, and manual controls for the (zoned) HVAC systems.
Fire extinguishers, which can be operated by the staff in an emergency, should be in all ICU and operating rooms (carbon-dioxide extinguishers are preferred in operating rooms, since they do not produce powder). The growing use of lasers for surgical procedures has made the operating room more vulnerable to fires.
A hospital evacuation may be compared with a shipboard evacuation in that they both stress limited movement for necessary control. Generally, patients are moved from one wing of the hospital to another—from one smoke barrier to the next barrier. When indicated, the nursing staff performs immediate horizontal evacuation of patients to areas of refuge beyond corridor smoke-barrier doors.
Ambulatory patients, led by a nurse in the unit, are evacuated first; then semiambulatory patients (those who can be helped into wheelchairs); and finally patients who must be moved with their beds.
The safety officer for the facility, mandated by JCAHO, reports to the incident site and functions in the role of the “second due” for the head nurse—assisting with the horizontal movement of patients to a primary refuge area. The hospital staff is trained according to the JCAHO-mandated RACE approach:
Remove—patients from room of origin.
Alarm—activate the fire alarm system.
Confine —the fire by closing doors and windows.
Extinguish —an incipient fire and/ or Evacuate the area.
This procedure initiates life safety measures.
Smoke containment is based on compartmentation. The room of the fire’s origin is the site of the first containment, which might be accomplished simply by closing the door to the room. The goal is to deprive the fire site of oxygen. Should the fire start at the nurses’ station, which is in an open hallway, the doors to all patient rooms are closed. Nurses are trained to place wet linens under the doors to create a seal that will prevent smoke from reaching patients inside the rooms.
Clinical outpatient areas. Patients in these one-day ambulatory areas may need assistance during an evacuation. In this case, the RACE procedure will be implemented. The evacuation approach may vary according to the type of treatment the patient is undergoing.
Preplanning a health-care facility familiarizes firefighters with the layout of the buildings within the hospital complex; their hazardous areas, construction features, and mechanical systems; and the threats to life safety-information the incident commander needs to formulate operational plans for safely and rapidly concluding the incident *