FIRE SAFETY PROTOCOLS & POLICY

PURPOSE/Aim:
This policy outlines the requirements and procedures to be followed to protect staff, students, patients,
visitors, and property in the event of a real or suspected fire that requires evacuation from the hospital
premises.

APPLICABILITY/SCOPE:
All the employees, patients, students, visitors will be governed by provisions of this policy.

ACRONYMS:
 CODE RED: The hospital's emergency code word to initiate a response to a FIRE. A notification of “Code
Red” alerts hospital personnel to respond properly to a fire while keeping patients, visitors, and the
general public from undue alarm or panic.
 CODE RED ALL CLEAR: An announcement which indicates to hospital personnel that the danger of the
fire or the fire drill has ended.
 R.A.C.E: An acronym that hospital personnel use to remember their duties in case of fire. It stands for
RESCUE, ALARM, CONFINE, EXTINGUISH/EVACUATE.
 P.A.S.S: An acronym that hospital personnel use to remember their duties for discharging a fire
extinguisher. It stands for PULL, AIM, SQUEEZE, and SWEEP.

PROCEDURES ON FIRE PRECAUTIONS AND PREVENTION:

To limit the risk of fires, employees at GSL will be responsible for practicing the following procedures for fire
safety:
 Make sure that doors, hallways, stairs, and other exit routes are kept free of obstructions.
 Properly dispose of combustible waste.
 Use and store flammable materials in well-ventilated areas away from ignition sources.
 Store incompatible (i.e. chemically reactive) substances away from one another.
 Perform lab procedures as outlined in Hospitals Lab Safety Handbook, including performing open flame
procedures only in a controlled and well-ventilated area.
 Keep all mechanical & electrical equipment in good working order.
 Regularly inspect electrical wiring and appliances regularly and keep machine tools free of dust and
grease.
 Ensure heating units are safeguarded.
 Report all gas leaks immediately.
 Repair and report spills for immediate clean up of flammable liquids.
 Turn off electrical equipment when not in use, unless otherwise designated.

GSL HOSPITAL & BUILDINGS CONTROL MEASURES

FIRE EVACUATION PLANS

The fire plan provides people with detailed protocols for responding when a fire or suspect fire occurs within
the hospital. Details also include:

 Emergency escape routes.

 Floor plans identifying the locations of the following
o Exits
o Primary evacuation routes
 o Secondary evacuation routes
o Accessible egress routes
o Areas of refuge
o Manual fire alarm boxes
o Portable fire extinguishers
o Occupant-use hose stations
o Fire alarm and controls
o Sprinkler control valves
 Fire alarms location
 Occupancy Assembly Point
 Fire hydrants locations

Equipment: GSL Hospital Buildings has fire extinguishers, fire blankets, etc. Equipment is located in every
hospital department.

Fire Alarms at GSL Hospital & Buildings are loud, audible. When the fire alarm is activated in GSL Hospital the
following will occur: The system uses loud audible beeps. This indicates that the system has detected a fire
event in the adjacent zone or compartment.

ACTIVATION OF CODE RED:

CODE RED should be immediately initiated whenever any one of the following indications of real or suspected
fire is observed:
1. Seeing smoke or a fire.
2. Smelling smoke or other burning material.
3. Feeling unusual heat on a wall, door or other surface.
4. Other indications as identified by the facility.

In an emergency, everyone is responsible for activating the emergency fire alarm. Employees at GSL Hospital
& Buildings are trained to know locations of fire alarms. It is each employee’s responsibility to sound the fire
alarm in a fire emergency.

Emergency Phone Number: DIAL X (To be constituted)

If there is no fire alarm box nearby, dial X. Give your name, location and a description of the problem. Speak
slowly and clearly. Wait to answer any questions or receive instructions the dispatcher may have. Stay on the
line until the dispatcher hangs up.

Emergency team: (To be constituted)

An emergency team has been constituted for the purpose of tackling and handling situation in the event of a
fire within the hospital building.

A CODE RED alarm also may be initiated automatically by electronic fire detection equipment, heat and
smoke sensors, ventilation equipment, and water pressure sensors. Fire response procedures must be
implemented upon suspicion of a fire. Notification of coworkers for a timely, effective and efficient
response is critical.

Upon activation of a fire alarm in case of fire, the fire department will be notified of the hospital’s urgent need
of assistance and will respond to assist in evacuation of patients, visitors, and employees.
An example of a brief action outline using the RACE acronym follows:
1. Remove/Rescue patients and personnel from the immediate fire area.
a. Evacuate patients to a safe area beyond smoke barrier doors.
b. Attend to injured and/or non-ambulatory persons.
c. Disconnect exposed oxygen lines from wall outlets.
2. Alarm/Alert/Activate the fire alarm and notify others in the affected area to obtain assistance.
3. Contain the fire and smoke by closing all doors. (Confirm/Call Fire department)
4. Extinguish the fire if it is safe to do so. (Evacuate)
a. Fire extinguishing methods are techniques- the acronym PASS is often used.
i. Pull the pin;
ii. Aim the extinguisher at the base;
iii. Squeeze the trigger; and
iv. Sweep the extinguisher’s contents back and forth across the base of the fire.

EVACUATION: The hospital policy is to evacuate immediately when an alarm is sounded, unless otherwise
designated by GSL Fire Staff. GSL Hospital & Buildings’s general evacuation procedures will be followed as
designated in Hospital Evacuation plan. The objective is to get as many patients and yourself to safe refuge
areas as quick as possible. Occupants should continue to evacuate area until “All Clear” is announced.
People designated for evacuation should know basic methods. They should be taught the following. 2, and 4
handed lifts. Fireman's lift from the bed. Human Crutch. Blanket removal. Wheel Chair. Pick a back. Fore and
Aft method. Removal Downstairs. Removal by stretcher.

GSL FIRE GENERAL PROTOCOL

Remember the basic fire protection procedure:

 During a fire emergency, initial evacuation of persons in immediate danger must take precedence over
all other actions.
 If safe to do so, extinguish the fire. If you are trained and have the right extinguisher for the job,
extinguish the fire.
 If a fire cannot be extinguished and threatens a patient care area, employees should activate
emergency fire alarm and remove as many patients as possible without putting their own life in
immediate danger
 Raise the alarm to alert others around you.
 All Major power operating units must be stopped by informing the engineering & electrical services.
 Evacuate the ward or department. Investigate, decide, evacuate.
 Take with you all patient records and other essential documents.
 Assist patients and special needs persons to designated exit. Continue to evacuate even if alarm stops.
 Do not use elevators! Use the stairs. Follow general evacuation protocol.
 Close and secure all doors and windows behind you to reduce the spread of the fire.
 In case you are stuck inside a room and unable to evacuate, seal the doors with wet towels or sheets,
and seal air ducts or other openings where smoke may enter.
 Open windows a few inches a top and bottom unless flames and smoke are coming from below. Do not
break any windows.
 If conditions appear life-threatening, open a window and wave a towel or sheet to attract the attention
of firefighters.
  If smoke conditions worsen before help arrives, get down on the floor and take short breaths through
your nose. If possible, retreat to a balcony or terrace away from the source of the flames, heat or
smoke.
 Get out and stay out. Assist in evacuation of patients and visitors, remember your part in the
evacuation plan – if in doubt ask NOW!
 Account for all patients and for others who work with you to ensure everyone has evacuated.
 Non-ambulatory patients should be covered in fire blankets and taken to the nearest exit and assisted
to outside of the building. Ambulatory patients should be directed to safe areas outside of the building.
 Give any information about the fire or about persons who may still be in to emergency fire personnel.

RECOVERY:
The Designated GSL Fire Team will obtain a detailed damage assessment of any area in the facility and
officially document the damage for insurance purposes, including:
 Direct fire damage
 Smoke damage
 Equipment damage
 Supplies lost
 Injuries/fatalities
 Water run-off
 Other operational damage/needs

FIRE DRILLS AND TRAINING:

 Fire drills will be conducted at (quarterly) intervals for the security guards and core team. Records are
maintained indicating the time, date, staff present, who conducted drill, nature and scope of the drill,
weather conditions and duration taken to evacuate.
 Trainings are held (quarterly) to instruct employees how to locate alarms and identify their codes,
assign responsibilities for patient safety, and locate exits.
 Assigned employees with specific duties are trained to know the locations and proper use of portable
fire extinguishers.

PLAN MAINTANANCE:
The GSL Designated Fire Team will ensure that equipment is maintained according to manufacturers’
specifications.
Hospital engineering service provision for Fire Protection according to NABH:

Fire fighting installation approval must be obtained

Location of control room should be easily accessible.
Control panel & manned, PA equipment should be connected with detection system or fire alarm system.
Pumps and pump room
2 separate pumps i. e .Electric and diesel pump should be available
Provision of Forced ventilation should be there.
Arrangement of filling Fire tenders
4 way fire inlet must be present in case of emergency
Proper access for Fire tender to fire tanks
Fire Drill should be performed
Yard Hydrants should be available
Ring main and yard hydrants should be as per strategic locations.
2 way fire heads to charge the ring main
Landing Hydrant & Hose reels
Wet riser system must be installed
First aid Fire fighting appliances must be in working conditions
First aid equipment cabinets
Provision of Escape routes - escape stair
Sprinklers system - basement & bldg. above 15 M in height
Automatic Smoke detectors / heat detectors
Provision of Fire Alarm System & Fire extinguishers