Banff Mineral Springs Hospital EMERGENCY RESPONSE CODE RED Fire
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1 Banff Mineral Springs Hospital EMERGENCY RESPONSE CODE RED Fire EMERGENCY RESPONSE CODE RED ALGORITHM Staff Member Discovering Fire If you smell or see smoke activate the fire alarm (fire pull station) and investigate the origin Discover fire? Follow R.E.A.C.T. (Appendix I) Put on the green Incident Commander vest. All Staff Assigned to Affected Area When hearing a Code Red announcement, Return immediately to your work area if safe to do so and report to your Supervisor Follow R.E.A.C.T. (Appendix I) if not already initiated Supervisor / Designate of Affected Area Upon confirmation of a fire or on hearing the fire alarm, ensure the steps of R.E.A.C.T. (Appendix I) are completed Call Patient Registration / Designate at 0 and state Code Red / Location Request Fire Department response (if Patient Registration does not call 911, ensure this is completed) Return to area to assist Notify Site Administration / Manager On-Call Consult with Protective Services (if on site) / Fire Marshal to determine when to announce the All Clear Patient Registration / Designate Upon receiving notification check the Fire Alarm Control Panel to determine location of alarm activation. Advise all staff: Code Red / Location (three times) Call to report the fire Notify Site Administration / Manager On- Call (if not already done) When directed by Site Admin / Manager On- Call / Fire Marshal, announce: Code Red / Location / All Clear (three times) Protective Services (if on site) Respond to the affected area Provide assistance to staff and Fire Department as needed Consult with Supervisor of affected area / Fire Marshal to determine when to convey All Clear Reviewed and Approved By Covenant Health Emergency/Disaster Management Page 1 of 7
2 EMERGENCY RESPONSE CODE RED ALGORITHM Staff in areas adjacent to / one floor above / one floor below the alarm area When hearing a Code Red announcement: If from an adjacent work area, or an area one floor above or one floor below, return immediately to your work area if safe to do so and report to your Supervisor Prepare for possible escalation of the Code Red, resulting in evacuation of your area or receiving evacuees from the affected area (see Code Green) Staff responding to support the area in alarm A representative from other departments/units should respond to the code. Assist in movement of all persons away from the immediately affected area Identify and locate all evacuation devices in case of escalation (i.e. sleds, stretchers, wheelchairs) Clinical and Support Staff in the Affected Area under alarm Clinical and Support Staff (i.e. Laboratory, Therapies, Nutrition Services) in an area when an emergency occurs are to stay and provide support until released by the Supervisor / Designate of that area Staff are to advise their own Supervisor / Designate when able, of their location and involvement in the response. Site Administration / Manager On-Call Consult with Supervisor of affected area / Protective Services / Fire Department to determine actions, based on risk Escalation of evacuation (see Code Green) Determine need to establish Site Command Post to coordinate actions and communications to staff Ensure notification to Senior Leadership, Communications, E/DM ( and ask operator for E/DM on call) RAAPID via Incident Notification Algorithm Ensure Urgent Notification of an Emerging Issue form has been completed In consultation with engaged parties determine when incident has resolved: Advise Patient Registration / Designate to announce All Clear (three times) Ensure all other incident documentation has been completed Reviewed and Approved By Covenant Health Emergency/Disaster Management Page 2 of 7
3 Site: Banff Mineral Springs Hospital Approval Level: Covenant Health E/DM Cross Reference: Emergency Response Code Green Document #: ERC 2 Initial Effective Date: October 2016 Revision Effective Date: October 2017 PURPOSE Emergency Response Code Red is the designated phrase to alert personnel to smoke / fire and details the actions to be taken by staff and physicians to ensure the safety and security of themselves, their patients and visitors. APPLICABILITY Emergency Response Code Red applies to all personnel. ACTIVATION Emergency Response Code Red can be initiated by any member of staff or physician who witnesses or recognizes smoke or fire that requires an immediate response by following the preceding algorithm. Reviewed and Approved By Covenant Health Emergency/Disaster Management Page 3 of 7
4 POST INCIDENT ACTIONS For a facility impacted by an Emergency Response Code Red, the manager in charge is to: Assess for injuries and facility damage. Implement subsequent emergency response plans as appropriate. Complete incident documentation as follows: o Reportable Incident Form (Senior s Health / Continuing Care sites). o Urgent Notification of an Emerging Issue (all other sites). o Other site or Covenant Health specific documentation as appropriate. Report incident to Fire Safety Consultant at Advice on document completion may be sought from Emergency/Disaster Management on-call staff ( and ask operator for E/DM on call) or from the Local Administrator/ Manager on-call (during evenings and weekends). Emergency/Disaster Management staff may also be contacted for assistance in facilitating the post incident debriefing. REFERENCE Corporate Policy I-25 Emergency/Disaster Management Response Reviewed and Approved By Covenant Health Emergency/Disaster Management Page 4 of 7
5 Appendix 1 REACT The following steps are interchangeable and do not have to be followed in the order outlined Remove those in immediate danger Evacuate the fire room, closing the doors behind you. Evacuate rooms adjacent to the fire room, closing the doors behind you. Ensure that patients/clients, visitors, staff and others not assigned fire duties, are safe and out of danger of the fire. Ensure room doors are closed Ensure all room doors and windows within your fire zone are closed. Ensure all obstructions are removed from corridors. Activate the fire alarm Pull the nearest fire alarm pull station. See Appendix 2. Call Patient Registration / Designate at 0 or Depending on location Inform the operator of Code Red / Location Try to extinguish or control the fire If safe to do so, try to extinguish the fire. See Appendices 3 and 4. If safe to do so, and where applicable, disconnect electrical equipment and remove flammable material from the vicinity. Ensure staff assigned fire duties at the scene are manning the fire extinguishers and fire doors. Ensure unauthorized persons are kept out of the area. Ensure arriving Fire Fighters are led to the scene of the fire. If the fire is too big or you are not confident in attempting to extinguish the fire don t try. Remove anyone in the room, back away and close the door. Once the door to the room with the fire is closed, it should not be re-opened. Reviewed and Approved By Covenant Health Emergency/Disaster Management Page 5 of 7
6 Appendix 2 GENERAL ALARMS MANUAL PULL STATION General Alarm Bells may be sounded during a fire or evacuation by one of the following methods: First Function. By pulling the handle, you activate the Alert Stage and trigger a slow ringing of bells or speakers (20 beats per minute). Second Function (general alarm). After 5 mins the alarm will automatically be upgraded to a general alarm (120 beats per minute) or can be immediately initiated by using an alarm key as per local protocol. The general alarm upgrades the emergency response process for the facility and may trigger an evacuation of the affected areas. During the second function the door to the Safe Room in Emergency Department will automatically unlock. For evacuation phases 2, 3 and 4 refer to Emergency Response Code Green in the Emergency Response Manual. Use a fire extinguisher only if: Everyone has left, or is leaving, the area FIRE EXTINGUISHER USE Reviewed and Approved By Covenant Health Emergency/Disaster Management Page 6 of 7 Appendix 3 The fire is small and is confined to the immediate area of origin (e.g. wastepaper basket, cushion, small appliance) and: o The fire is not growing rapidly o The fire has not produced, and is not producing, a lot of smoke o You have been trained in the use of the extinguisher and you are confident you can operate it effectively You are sure that: o The extinguisher is designed for the type/class of fire at hand o The extinguisher is large enough to fight the fire o You are able to extinguish the fire o You can fight the fire with your back to a safe escape route If any of these conditions are not met, evacuate the area immediately, closing all doors behind you. Leave the fire fighting to the Fire Service.
7 Appendix 4 P.A.S.S. P.A.S.S. should be used for the operation of all portable fire extinguishers: Pull the pin. Give the pin a half twist in order to break the seal Aim low. Aim the extinguisher nozzle, horn or hose at the base of the flames Squeeze the handle. This releases the extinguisher agent Sweep from side to side. Sweep back and forth with the extinguisher aimed at the base of the fire until the fire is put out. Watch the fire area. If the fire breaks out again, repeat the process. Reviewed and Approved By Covenant Health Emergency/Disaster Management Page 7 of 7
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