Section: Health and Safety Date of Issue:

Title: Fire Emergency Response Plan (Code Red if applicable Revised Date:
at your site)
Approved by: Policy #

Purpose
The Fire Emergency Response Plan alerts personnel to smoke and/or fire and details the actions to be
taken by staff to ensure the safety and security of themselves, their patients/clients and visitors.

Policy
[Organization name] is committed to preparing for all types of foreseeable emergencies. All staff are
required to follow the Fire Emergency Response plan when activated in response to a fire and/or smoke.

Responsibilities
The Fire Emergency Response applies to all personnel.

Procedure
1. ACTIVATION

The Fire Emergency Response plan can be initiated by any staff member who witnesses or
recognizes smoke or fire that requires an immediate response by following the algorithm above.
2. POST INCIDENT ACTIONS

For a facility impacted by a Fire Emergency, the (designate) in charge is to:

 Assess for injuries and facility damage.

 Implement subsequent emergency response plans as appropriate.
 Complete incident documentation as follows:
o Site Specific Reportable Incident Form
o Other site-specific documentation as appropriate.

Forms

Appendix 1: REACT
Appendix 2: GENERAL ALARMS – MANUAL PULL STATION
Appendix 3: FIRE EXTINGUISHER USE
Appendix 4: PASS

References

Cross Reference:
Evacuation Emergency Response Plan

Page 1 of 6
 Section: Health and Safety Date of Issue:
Title: Fire Emergency Response Plan (Code Red if applicable Revised Date:
at your site)
Approved by: Policy #

EMERGENCY RESPONSE ALGORITHM

If you smell or see smoke:
Staff Member

If you discover fire, or

Smoke / Fire
Discovering

 Alert those in your immediate work area by yelling ‘Fire Emergency / if the source of the
Location’ smoke is not certain:
 Activate the fire alarm (fire pull station) follow R.E.A.C.T.
 Investigate the origin of the smoke. Do not enter through a closed door (see APPENDIX 1)
if fire is suspected in that room or area (additional air movement
entering a room may cause fire to flare up)

When hearing a ‘Fire Emergency’ alert in your work area, assist in moving those
All Staff Assigned

in immediate danger to a safe location, if it is safe to do so.

to Area in Alarm

Follow R.E.A.C.T.
If you are away from your work area, and upon hearing a ‘Fire Emergency’
(APPENDIX 1),
announcement, return immediately to your work area if it is safe to do so and
if not already
report to your Supervisor
initiated
If you are unable to return to your work area, report to the designated
evacuation destination for your work area (see Evacuation ERP)

 Announce “Fire
When directed by Site Admin /
Emergency /
of Area in Alarm

Insert Site Specific Leadership

Upon confirmation of a fire Location”(three
Supervisor

title announce:
or on hearing the fire times)
“Fire Emergency / Location /
alarm, ensure the steps of  Call 911 and
All Clear” (three times)
R.E.A.C.T. (APPENDIX 1) request Fire
Site specific variations to
are completed Department
overhead announcements and
response
internal activations
 Return to area to
assist
 Notify Site
Supervisor / Person InCharge

Upon receiving notification, advise all staff:

 “Fire Emergency / Location” (three When directed by Site Admin / Insert Site
times) Specific Leadership title:
 Site specific variations to overhead  “Fire Emergency / Location / All
announcements and internal activations Clear” (three times)
 Call 911 to report the fire  Site specific variations to overhead
 Notify Site Administration / Insert Site announcements and internal
Specific Leadership title (if not already activations
done)
 Provide assistance to staff and the Fire
Department as needed

Page 2 of 6
 Section: Health and Safety Date of Issue:
Title: Fire Emergency Response Plan (Code Red if applicable Revised Date:
at your site)
Approved by: Policy #

EMERGENCY RESPONSE ALGORITHM

When hearing a ‘Fire Emergency announcement
not directly impacted

 All staff are to return to their work areas if it is safe to do so

Staff in areas

by the alarm

 Specifically, if from a work area adjacent to the area in Prepare for possible escalation
alarm, or an area one floor above or one floor below to the of the ‘Fire Emergency,
area in alarm, return immediately to your work area if it is resulting in evacuation of your
safe to do so and report to your Supervisor area or receiving evacuees
 If you are unable to return to your work area, report to the from the affected area
designated evacuation destination for your work area (see (see Evacuation-ERP)
Evacuation-ERP)
Staff responding to
support the Area

Staff responding to support the Area in Alarm are to focus on:

 Assisting in the movement of all persons away from the immediately affected
in Alarm

area
 Identifying and locating all evacuation devices in case of escalation (e.g.
evacuation devices, stretchers, wheelchairs)
 Do not bring fire extinguishers from adjacent areas, as this may deplete needed
resources for that area
Staff in the Area in Alarm
Clinical and Support

Clinical and Support Staff (e.g.

Portering, Therapies, Nutrition
Services) in an area when an Staff are to advise their own
emergency occurs are to stay and Supervisor when able, of
provide support until released by the their location and
Supervisor of that area, if it is safe involvement in the response
to do so

Consult with the  Determine need to establish a In consultation with

Supervisor of the Area Site Command Post to coordinate engaged parties
Insert Site Specific Leadership title

in Alarm / Security / Fire actions and communications to determine when

Department to staff incident has resolved:
Site Administration /

determine actions,
 Ensure notification to  Advise
based on an Switchboard /
(Insert Zone Specific
assessment of risk Designate to
Contact)
presented by the announce ‘All
incident Clear’ (three
 Escalation of
evacuation (see
Code Green)
Ensure Site Specific Ensure all other incident
Reportable Incident documentation has been completed
form has been
completed

Page 3 of 6
Section: Health and Safety Date of Issue:
Title: Fire Emergency Response Plan (Code Red if applicable Revised Date:
at your site)
Approved by: Policy #

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, 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 911
 Where applicable, Site Specific procedures may indicate notification of Switchboard
Operator / Designate at _____________, who will notify 911
o Inform 911 dispatch of the fire situation and your location
o If contacting the Switchboard Operator / Designate, inform the operator of
“Code Red / Location”

Try to extinguish or control the fire

 Do not attempt to extinguish or control a fire alone. Have another person with you
who can help to ensure your safety
 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 of the fire
 Ensure staff assigned fire duties at the scene are manning the fire extinguishers and
fire doors
 Staff initially responding should bring additional extinguishers from unaffected areas
to the fire zone. Do not bring extinguishers from adjacent areas, whereby their
resources will be depleted
 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 – do
not 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

Page 4 of 6
Section: Health and Safety Date of Issue:
Title: Fire Emergency Response Plan (Code Red if applicable Revised Date:
at your site)
Approved by: Policy #

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

For evacuation phases 2, 3 and 4 refer to Emergency Response Code Green in the
Emergency Response Manual.

APPENDIX 3: FIRE EXTINGUISHER USE

Use a fire extinguisher only if:

 Everyone has left, or is leaving, the area

 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
o Ensure you are not alone when attempting to fight a fire
 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 firefighting to the Fire Service

Page 5 of 6
Section: Health and Safety Date of Issue:
Title: Fire Emergency Response Plan (Code Red if applicable Revised Date:
at your site)
Approved by: Policy #

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

Page 6 of 6