fire safety plan - fhs.mcmaster.ca

Hamilton Health Science Fire Safety Plan –McMaster Children’s Hospital

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FIRE SAFETY PLAN FIRE – LIFE EMERGENCY – 5555

GENERAL ENQUIRES

MUMC SECURITY – 76444

SECURITY CONTROL CENTER 77753

MUMC ENGINEERING 75501

1200 King St W

Hamilton, Ontario


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Emergency Fire Safety and Evacuation

The Fire Emergency Plan - Instruction Guide has been compiled as the

predominant document to the HHS Code Red and Green Procedures.

This information is intended to provide detailed direction on procedures and

protocols to be followed in the event of a fire in the Hospital.

Staff must be familiar with this content as well as the Corporate Code

Red Procedure and their Area-Specific Code Red and Green

Procedures


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TABLE OF CONTENTS

General Inquiries.............................................................................................1

• Phone numbers for general inquiries

INTRODUCTION…………………………………………………………………….4

Purpose and Goal

RESOURCES of BUILDING …………………………………………….…………6

Description of Building

Occupants

Ownership

Escalation List

Life Safety Systems

Electrical, Utility & Fuel Supply

1.0 Fire Alarm ................................................................................................. 9

1.1 First Stage

1.1.1 First Stage Alarm H.E.A.T 1.2 Second Stage

2.0 Evacuation............................................................................................... 11

2.1 Preparation for an evacuation 2.2 Progressive Stages of Evacuation 2.3 Evacuation by Compartments 2.4 Horizontal Evacuation 2.5 Vertical Evacuation 2.6 Total Building Evacuation

3.0 ResponsibilitiesofStaff............................................................................13

3.1 Program, Service, Department Manager Responsibilities 3.2 Emergency Code Captain – Area Charge Person 3.3 Area Staff 3.4 Telecommunications

3.5 HHS Fire Response Team

3.6 Administration Responsibilities

4.0 Fire Response......................................................................................... 19

4.1 REACT, Smell of Smoke 4.1.1 First Stage Alarm for Staff, Patient, Visitors

4.1.2 Second Stage Alarm 4.2 Types of fires and extinguishers 4.3 Fire Hose 4.4 When to fight a fire


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5.0 Fire Safety for Occupants .......................................................................22

5.1 Staff Responsibility 5.2 Occupant/Staff training

6.0 Fire Hazard Control .................................................................................23

6.1 Building decorations 6.2 General/Personal Housekeeping

6.3 Storage, Handling and Use of Flammable Liquid

6.4 Open Flame Hazards Control

6.5 Unobstructed Access to Exits – Clear Corridors

6 .6 Electrical equipment and Appliances

6.6 Extension Cords

6.7 Portable electrical Heaters

7.0 Fire Safety Maintenance Regulations Ontario Fire Code………………………………….27

7.0 Engineering and Security Service’s - Fire Safety Maintenance Requirements

Appendix A – Code Green – Procedure for Evacuation ………………………………………....32 Appendix B – Use of voice communication building automation system and elevator ….…....43 Appendix C – 3G Child and Youth Mental Health Program………………………………….…...47

CAF (Central Animal Facility)

Appendix D- Code Brown / Hazardous spill control procedure……………………………….….49

Appendix E – Fire Site Plan ………………………………………………………………………...55


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Purpose and Goals This document must be kept available on the premises at all times for the use of supervisory

personnel; such personnel should be fully aware of their duties and responsibilities contained

herein.

The Fire Safety Plan (FSP) has been prepared to assist in the safe handling of a fire or smoke situation;

The fire procedure will assist all staff, visitors and patients in safe and effective response to a fire or smoke situation

Every member of HHS has a responsibility to maintain knowledge of the fire safety plan, supporting procedures and has a responsibility to participate in fire prevention.

The “Owner” is responsible to completely review the material contained herein and to ensure

that any errors or omissions are corrected. The on-going integrity of this Fire Safety Plan must

also be maintained in order to conform to the ONTARIO FIRE CODE and to ensure occupant

safety.

The Fire Protection and Prevention Act states that any person who contravenes any provision

of the Fire Code is guilty of an offence. Upon conviction, any company or corporation is liable to

a fine of not more than $500,000. Any individual, director or officer of a corporation is liable to

a fine of $50,000, a term of imprisonment of not more than one year, or both.

The Fire Department may require this Plan, or any part thereof, once approved, to be

resubmitted if any changes are made to the content, whether it be because there have been

changes to occupancy or use, or standards, or because the Chief Fire Official judges the current

Plan to be no longer acceptable. The Chief Fire Official is to be notified if any changes are made

to the Plan.

While it is reasonable to believe the Fire Department will assume command upon their arrival

at a fire emergency, it is nevertheless the responsibility of the owner(s) to ensure the safety of

the occupants at all times.

It is not necessary that the manager staff be in the building on a continuous basis, but they shall

have a delegate and be available on notification of a fire emergency, to fulfill their obligation(s)

as described in the Fire Safety Plan.

The absence of supervisory staff when a fire occurs could result in a failure to provide the

services required of supervisory staff pursuant to Section 2.8.2.2 of the Ontario Fire Code.

Supervisory staff shall be instructed in the fire emergency procedures as described in the Fire

Safety Plan before they are given any responsibility for fire safety.


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DESCRIPTION OF BUILDING

Building Information

Common Name McMaster Children’s Hospital (MUMC) Doc. File # (Fire Department use)

Address: 1200 King St. West

City: Hamilton Postal Code: L8S 4K1

Number of Stories: 4 Occupied Floors 7 Mechanical Floors 1 Underground Parking

Number of Beds: 120 Building Area: 1.2 M Sq. ft (occupied) 1.2 M Sq. ft (Mechanical/Parking)

Indicate which of the following activities take place in your building: Public Assembly Institutional (Hospital, Nursing/Group Home) Residential Office (includes medical offices) Mercantile/Retail Industrial

Indicate which of the above the major part of your building is. Hospital

Describe in your own words the business operations taking place in your building: Children’s Hospital/McMaster University classrooms and Labs

Building Facilities

Do you have a parking garage? Yes No

Do you have an elevator? Yes No

Is there a firefighter elevator? Yes No

Do you have smoke control devices? Yes No

Do you have pressurized stairwells? Yes No

Is there interior roof access? Yes No Where? Accessible from top of west stair

Do all stairwells exit to the exterior? Yes No If no explain?

Do you have hazardous materials stored on site? Yes No Location: Every department has a copy of the WHMIS binder as it applies to their specific area.

Building Access

Lock Box Chubb Location: Fire department access: Security will assist Knox Other Type

Entry Code

Onsite Building Information

Fire Safety Plan Revised Date: July 6,2020 Location:

WHMIS Information Location:

Other Location:

Occupants

Patients Approx... 200-300

Total


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Ownership

Building Owner: Hamilton Health Sciences Phone: Res: (905)521-2100 Cell: ( )

Address: 1200 King St West Bus:(905) Ext:

City: Hamilton Postal Code: : L8N 3Z5 Fax:( ) Pager:( )

Email:

Escalation List: ACTIVE CODE RED ONLY .

1.

Name: Director-on-Call Phone: Res: (905)521-2100 ext. 0 Cell:( )

Position: centralized resource Bus:(905) Ext:

Pager:( )

2.

Name: Facilities Manager on call Phone: Res: (905)521-2100 ext. 0 Cell:( )

Position: Engineering Bus:( 905) Ext:

Pager:( )

3.

Name: Phone: Res: ( ) Cell:( )

Position: Bus: (905)

Address: Fax: ( ) Pager:( )

Contractors – Service Company These are your contractors or fire alarm company personnel to be contacted in the event of problem requiring fire alarm or other maintenance at this building.

Name: Simplexgrinnell

Phone: Res: (905)577-4077 Cell:( )

Position: Fire Protection Contractor Bus:(905) Ext:

Address: 1-40 Hempstead Dr. Hamilton

Fax( ) Pager: )

Name: Protectron Phone: Res: (844)2304691 Cell:( )

Position: Monitoring Company Bus:1 (800) Ext:

Address: 8481 Langelier Blvd Montreal Qc Fax:( ) Pager:( )

Alarm Systems (If no fire alarm is present in the building, leave this blank and go to the Fire Protection Devices section.)

Main Fire Alarm Control Panel Location: Main entrance

Remote Annunciators Location(s): Switch Board, Ewart Angus Entrance, 6th Floor TS6,

Type of Alarm (Check the appropriate box below.)

Single Stage Two Stage Interconnected Smoke Detectors

Security/Intrusion Partial System Sprinkler System used as Fire Alarm

Fire Protection Devices (Check any that are present in your building)

Smoke Alarms (Battery or hardwire) Emergency Lighting (Generator)

Smoke Detectors (Alarm System) Carbon Monoxide Detectors

Heat Detectors Fire Extinguishers

Evacuation Communications System (PA) Communication (Phones)

Kitchen Hood Suppression System Other Magnetic hold opens for zone fire separations on each floor/wing. Magnetic locks will disengage upon activation of the fire alarm system.


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Water Supply

Is there a fire hydrant within 90 meters of your buildings front door? Yes No

Sprinkler System

Do you have a sprinkler system in your building? Yes No (If no, go to Standpipe Systems.)

If yes, does it cover your whole building? Yes No

If no, what areas are sprinklered? Every Area except Level 6

If you have a sprinkler system in your building, the following devices must be indicated on the diagram of your building: Fire Department Connection (Siamese) Connection, Sprinkler Control Room, Fire Pump(s), Main Control Valve, Isolation Control Valve(s), and Post Indicator Valve(s).

Is your sprinkler connected to the Fire Alarm? Yes No

If no, is there a water gong or other alerting device to indicate water flow? Yes No

Standpipe System

Do you have a standpipe system in your building? Yes No (If no, go to Fixed Extinguishing Systems.)

If yes, does it cover your whole building? Yes No

If no, what areas are covered?

Do your fire hose cabinets have fire extinguishers? Yes No

How are the hose cabinet doors opened if they are locked or fastened? Finger latch on door

If you have a standpipe system in your building, the following devices must be indicated on the diagram of your building: Fire Department Connection (Siamese) Connection, Hose Cabinets, and Main Shut Off Valve.

Fixed Extinguishing Systems Do you have one? Yes No (If no, go to Utility Provisions.)

Area Protected Type Specify Details

Kitchen (NFPA 96) 1T1 – Main Kitchen

Spray Booth

Other Communication Level MM - Halon System– Telephone Room

Extinguishing System connected to Fire Alarm Yes : No

Electrical, Utility & Fuel Supplies (check all that apply)

Water Main Shut off Main Electrical Shut off Refer to maps

Natural Gas Shut off Fuel Oil/Diesel Shut off Refer to maps

Emergency Generator Location:

Refuse

Sprinkler Coverage

Garbage Room Location: Yes

Garbage Chute Location: Yes

Garbage Compactor Location: Yes

Garbage Exterior Storage Location:


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1.0 Fire Alarm

The Fire Alarm is a TWO stage alarm

1.1 First stage

The fire alarm can be activated by smoke detectors, heat detectors, or flow measurement of water within the piping of the sprinkler system. This flow will only take place if a sprinkler head allows water to flow. Fire pull stations are activated manually.

The first stage alarm consists of slow sounding bells striking at 20 bells per minute. This is the ‘Fire Emergency Alert’. The slow sounding bells are meant to alert staff without alarming patients and visitors. The bells maybe silenced after approximately 3 minute. This automatic silencing of the bells does NOT signify an all clear.

Once the Fire Department is satisfied that the situation has been rectified, approval is given, and the all clear shall be announced. The All Clear is announced by Telecommunications using the overhead paging system announcing: “CODE RED - ALL CLEAR…Zone / Area / Dept.” IF YOU HEAR THE 1ST STAGE ALARM (intermittent bell) OR DISCOVER FIRE

1. Investigate zones for fire without putting yourself at risk. Quickly sweep the common areas, patient rooms and service rooms on your assigned floor for signs of fire. Notify the switchboard immediately at 'ext. 5555' of any fire conditions – REACT and listen for announcements. Provide instruction for other staff in your area.

2. If fire is present attempt to rescue the occupant or control the fire situation and implement the

code RED protocol. You must evacuate that room and adjacent rooms very quickly and close all doors

3. Notify the switchboard at ‘ext. 5555’ notify them of the fire condition in your area. Be sure to

provide details of your remediation strategy and what was done to mitigate reignition.

4. Once rooms have been checked and no fire condition is present, advise patients to stay in their rooms and await instruction. In the event a patient or visitor is being uncooperative be sure to notify the switchboard at ‘ext. 5555’.


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1.1.1First Stage Alarm Specific Location Evacuation H.E.A.T During a first stage alarm there may be the need to evacuate an isolated unit or building. All staff is advised to refer to their area-specific Code Heat Evacuation procedures. If immediate assistance is critical, the Area in Charge Person is to request Switchboard to announce activation of H.E.A.T (Hospital Evacuation Assistance Team) & the area in need. On hearing the announcement all clinical and non-clinical areas are to deploy one staff member to the evacuation unit and report to the Area Charge Nurse there for appropriate assignment Areas or buildings that are required to evacuate shall proceed by using the safest route to ensure their safety;

The decision for further evacuation shall be made in conjunction with the Hamilton Fire

Department, who, upon their arrival shall assume a unified command with the hospital Incident

Manager.

1.2 Second stage alarm

Sounds at a rapid 120 bells / minute and if sounded if there is a need to evacuate the entire

building. Once the second stage of the alarm is initiated your total building evacuation

procedures come into effect. An overhead page / emergency code pager alert will be made

announcing:

“Code Green is now in Effect”

Second stage- Fire Alarm System Malfunction Procedure: Should the fire alarm system malfunction and cause and accidental activation of the Stage

Two – Total Building Evacuation alarm, the following procedure will be initiated.

1) An overhead page / emergency code pager alert will be made announcing:

“Code Green Standby”

This will be announced 3 times at 5 minute intervals until the “All clear” is given. All Wards and

Departments are to standby and maintain a high state of alert and preparedness to initiate an

evacuation should it become

2) Should a need to initiate a Stage Two - Total Building Evacuation occur an overhead page /

emergency code pager alert will be made announcing:

“Code Green in Effect”

This will be announced 3 times at 5 minute intervals and will be made in conjunction with the

stage two – total building evacuation alarm bells. All areas need to be familiar with their fire

emergency evacuation procedures. Refer to Appendix A HHS Code Green & H.E.A.T


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2.0 Evacuation

You must be prepared for evacuation. Know your exits, evacuation routes and procedures. After each

drill review, maintain and update your area-specific Code Red Procedures.

Areas of the Hospital are divided through compartmentation or special separations. These separations

are found between sleeping rooms, treatment rooms, departmental areas and corridors (smoke barrier

doors, every 75 feet along corridors).

The fire separations confine the fire to a specific area (point of origin) and take approximately 1 hour to

spread beyond an enclosed separation.

Compartmentation is only effective if the doors and windows are kept closed thereby confining the fire

and the smoke to the room of origin. Effective compartmentation allows time to stabilize and evacuate

patients and staff from the immediate danger zone and for the fire team / fire dept. to initiate fire

suppression procedures.

Staffing Levels with respect to fire evacuation procedures within the Hamilton Health Sciences

Corporation sites shall comply with the Office of the Fire Marshall and Emergency Management

(OFMEM), Ontario, technical guideline Staffing Levels in Care Occupancies, Care & Treatment

Occupancies and Retirement Homes (TG-01-2013).

2.1 Preparing for Evacuation

• If time allows generate patient and staff evacuation lists.

• Under no circumstances are patients to be moved in their beds. This constricts hallways and

corridors, endangering all of the area occupants.

• The placement of wet towels, blankets or sheets at the bottom of a closed door, assists with restricting

a rapid transfer of smoke and generates extra time with which to complete area evacuation.

• Adjacent Wards and Areas are advised to identify a buddy area who can provide mutual aid

assistance in a Code Red. This Code Red mutual aid assistance program allows for the immediate

addition of personnel from the adjacent areas to assist with the evacuation of an area that is in immediate danger.

• Your evacuation protocols are not to assume that unlimited assistance is available from the Fire

Department or other areas- exterior to your own. In most circumstances assistance is available;

however, there may be situations where you are required to complete your evacuation protocols with

the resources at hand.

• Ensure that you have ample space available in your evacuation staging areas to enable you to assemble your patients and resources.

• If time allows, prepare and gather priority medical resources (this includes blankets) that your area

deems necessary to maintain a minimum level of care for your patient population if evacuation

becomes necessary.


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Remember, once evacuation protocols have been initiated there are no guarantees that you are able

to gain access to another inpatient care area. Your resource items must be essential items only and

easily transportable (use a laundry or garbage bags).

• Have two horizontal evacuation routes, one primary route and one secondary route. These routes

are always in the opposite direction of each other and in many cases, the secondary route entails

traveling down the stairwell.

2.2 Progressive stages of evacuation

Progressive stages of evacuation in the event of heavy smoke contamination or a fire within your area

are: • room of fire or smoke origin, • then the adjoining rooms working out and away from the room of fire or smoke origin.

Affix masking tape at knee level from the door frame onto the center of the closed door of an

evacuated room to indicate that the room has been checked and cleared. Rolls of 2” masking tape

are contained within your emergency preparedness and evacuation resource kits.

2.3 Evacuation by Compartments

Once in the corridor between a set of smoke barrier doors this is a compartment and it is designed

as a point of refuge. By moving from compartment to compartment we can protect patients and

ourselves without transporting or moving too far. This is referred to as horizontal or horizontal

evacuation.

2.4 Horizontal Evacuation (Primary Evacuation Route)

To facilitate horizontal evacuation we need only move 3 or 4 compartments away from the danger

zone. Inpatient wards are advised to move toward an adjacent inpatient care area.

2.5 Vertical Evacuation (Secondary Evacuation route)

If you are faced with a vertical evacuation then movement is always down via the stairwell but

never up or below grade or ground level. It may be necessary, in this situation, to initially evacuate

to the exterior or outside of the building and then reenter via a main or side entrance.

Once you have arrived within another area-you follow their area-specific Code Red evacuation

routes and procedures. All Staff are reminded that in the event of any evacuation their assistance

may be required to aid in the movement of patients.

2.6 Second Stage Total Building Evacuation

During a second stage total building evacuation, staff are advised to refer to their area-specific Code

Green Evacuation procedures.

Total building evacuation entails exiting the building by the shortest route available. As with the

horizontal evacuation, there are always two routes planned, one primary and one secondary, each

in the opposite direction of the other.


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Staff must be prepared to apply maximum flexibility to their procedures. Evacuation routes may vary

but your destination does not.

Once a second stage evacuation is initiated all major resources, extra blankets, mattresses, medical

supplies, portable oxygen etc. are acquired from ground level areas only. The size of the fire or Hazard indicates the extent of the evacuation necessary. Horizontal evacuation can be self-initiated if there is a clear and present danger. The decision for further evacuation is made in conjunction with the Hamilton Fire Department who,

upon their arrival assumes command and control of the situation.

3.0 Responsibilities of Staff

3.1 Program, Service, Department Manager Responsibilities*

An effective area-specific Fire Safety Plan depends upon the knowledge, experience and

commitment of management personnel. Every supervisor must have a clearly defined role and the authority to respond appropriately. All new staff MUST receive training in the Fire Safety Plan before responsibilities can be delegated. Training for all staff members must be organized and be conducted at least annually. Conduct Unit/Dept. Code Red Fire Drill review at least monthly as required by law.

Unit / Department Manager

Ensures adequate staffing levels are sustained at all times to ensure that all functions can be

implemented as outlined in the Fire Safety Plan

• Ensures that Code Red area specific information is developed, current, and reviewed annually by

the Code Red Subcommittee • Designates an Area Code Captain responsible for fire safety; to maintain the area specific Code

Red Information (see EDM – HHS Area Specific Code Information Record Template) current &

available; to coordinate the regular training & education of Code Red to staff; to identify fire

hazards to the area Manager; complete and forward the necessary documentation to the Manager

for review. • Ensures all staff participate in monthly fire drills and required yearly in-services. • Ensures relevant documentation is completed (Code Red Fire Drill & In-service Staff Attendance

Records, Code Red fire Drill Summary Report, Annual Code Red Report). • Maintains a fire hazard free work area. • Shall identify and designate a Code Staging Area where staff shall report to in the event of an

Emergency Code such as a Code Red. • Ward Managers: will ensure that each in use isolation room be placarded on the patient corridor

side with a legible sign identifying it as an isolation room

*N.B. Medical Affairs is responsible for medical/midwifery staff, residents, interns and medical students

It is recommended that the Area-Specific Fire Emergency Protocols be broken down by protocol into

an instant access recipe / index card style system.


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3.2 Emergency Code Captain – Area Charge Person

The area Manager / Supervisor (or their delegate), is considered to be the Emergency Code Captain

(Area Charge Person) in their respective areas. The Emergency Code Captain (or delegate), is

responsible for coordinating and assigning personnel to carry out instructions in each area during a

Code Red condition. The Emergency Code Captain (or their delegate) should be easily and readily

identifiable by a safety vest.

Area Code Captain responsible for fire safety; to maintain the area specific Code Red Information (see EDM – HHS Area Specific Code Information Record Template) current & available; to coordinate the regular training & education of Code Red to staff; to identify fire hazards to the area Manager; complete and forward the necessary documentation to the Manager for review

The Area-Specific Fire Emergency Protocols are to be contained in the Area specific Emergency

Procedures Manual and is to be maintained and kept available by the Emergency Code Captain in

their respective areas.

BACK-UP COVERAGE

The integrity of the code captain program requires the cooperation of all staffs involved, even if just

following instructions. Daily communication between the team and assigning backup supervisory staff

to fill in where necessary should be accomplished as soon as possible

Placement of Infection Control Carts in Patient Corridors - Mc Master

University Medical Centre (MUMC)

Wards 3B, 3B-PEDU, 3C, 4B and 4C are permitted to locate isolation carts in the Ward corridors provided

the follow conditions are maintained at all times:

Patient corridors are to remain free of all other

obstructions/supplies/patient care accessories/laundry supplies/catering carts etc. not under transit or in use and under the immediate control of

hospital staff. Permanent storage of items/supplies is not allowed.

That each "in use" isolation room be placarded on the patient corridor

side with a legible sign identifying it as an Isolation room. Only

designated isolation rooms will be allowed to have an isolation cart

located adjacent to the room entry door in the patient corridor.

3.3 Area Staff

All staff return to their area via the stairwells only. DO NOT USE ELEVATORS unless

directed to do so by Fire Emergency personnel.

Staff are to move quickly but cautiously.

Approach stairwells and smoke barrier doors with due care and caution.


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Check to ensure that stairwells and beyond the smoke barrier doors are free and clear

of fire and smoke conditions.

Staff attending meetings at their home site immediately return to their respective areas.

Staff attending from other sites accompany home site Staff to their areas.

Further Intercompartmental movement is to be restricted to legitimate emergency

and urgent tasks only.

Staff already in their work area at the time of the alarm are to…

1. Sweep the work area and check:

• for fire conditions (smoke, heat, flame) • that all doors are closed • that all exits have clear access (clear corridors of all in use equipment and

carts – relocate Isolation Cart from corridor into the closest clean room) • that a portable fire extinguisher is available • inform the Emergency Code Captain (or delegate) as to who is present in the

work area • generate Patient and Staff evacuation list

2. Patients are evacuated in order of physical condition.

A. Ambulatory - minimum number of staff required to lead group to safe area;

B. Wheelchair patient (use improvised wheelchairs if necessary);

C Critical patients (those requiring the most resource to move) as they need to

be moved when the greatest amount of help is available – activate “HEAT”

protocol;

D. Those that resist.

3. Prepare important items for safekeeping or evacuation i.e. patient charts, priority

medical resources, and blankets. Items must not be cumbersome or constitute a

hazard during an evacuation. Staff are to maintain a hands free condition in order

to offer aid and assistance.

4. Designate a person to stand by the telephone and ensure that telephone use is

restricted to stat, emergency or urgent calls only. Confine inter-compartmental

movement to a minimum.

5. Ensure visitor, patient and staff movement are controlled.

6. Once staff are safely within their area they stay put unless there is a clear and

present danger, then the area-specific ‘Horizontal Evacuation Procedure’ is

initiated.

7. Review Horizontal Intercompartmental and Total Building Evacuation Routes. In-

Patient care areas - this review also includes “Lifts and Carries”.

8. STANDBY and await further instructions

9. REMAIN on emergency alert until the sounding of the all clear.

10. At the discretion of the manager or delegate staff may resume their duties within

the confines of their area only.


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Intercompartmental movement is to be restricted to legitimate fire and

medical emergency and urgent tasks only.

3.4 Telecommunications

On Smell of Smoke notification: • Pages HHS Fire Response Team (FRT), of "Smell of Smoke" level & location & awaits FRT

instructions

On Fire Alarm notification: • Confirms alarm and location • Calls Fire Dept. (911) & gives building address & alarm location • Pages FRT of Code Red level & location • Announces overhead as directed Code Red status Standby ; In-Effect; Level/location/zone • Announces overhead as directed Code Green status Standby, In-Effect, Level/location/zone

• If FRT confirms fire, contacts those on notification list • Others (as directed)

• Repeats overhead announcement every 5 minutes • Announces instructions and orders under the direction of the FRT and Hamilton Fire

Department • Alarm system is monitored by Alliance Protection. Upon receipt of alarm the monitoring

company calls 911. After the 911 call the Alarm monitoring company calls back to Switchboard

to alert and verify alarm condition

3.5 HHS Fire Response Team (FRT) Composition

While all staff have a significant role in responding to fire alarm situations, each site has

a core Fire Response Team that takes the lead in responding to fires & alarm situations.

Fire Response Team members include the HHS Fire Marshal/Fire Prevention Life Safety Officer (if on site), Security, Engineering staff, electricians,

plumbers, select Customer Support Service staff & other individuals with fire

protection/containment skills. Respiratory Therapy is also part of the Fire Response Team to manage areas with oxygen supplies. The HHS Fire Marshal/ Fire Prevention

Life Safety Officer is the Fire Response Team Lead if on site. Otherwise Security

takes the Lead role.

3.5.1 HHS Fire Response Team Role

• Go to alarm location & find source of smoke/fire • If fire confirmed, ensure pull station activated and a call is made to telecommunications • A small fire may be extinguished by the use of a portable fire extinguisher, only if the

smoke or fire dose not present danger to the operator, and the operator is trained in the

use of a fire extinguisher. • Contain / smoke / fire, until Fire Dept. arrives and assumes control of firefighting activities. • Assist in evacuation of fire area if required


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3.5.2 Engineering:

• As directed by Fire Response Team Lead, notifies Telecomm of status updates incl. "all clear" & area evacuation decision, destination & arrival

• All Air handling units within the quadrant in alarm immediately shut down on activation of

the fire alarm system. Under the direction of the Hamilton Fire Dept. Engineering staff

will adjust (shut down, startup) building services/systems as needed. This includes

manipulation of the air handling systems to create positive and negative pressure zones. • Resets fire alarm system following "all clear", arranges a Fire Watch in conjunction with

Security Services in the event of an alarm systems loss or zone isolation • Manages HHS' fixed & portable voice communication systems to facilitate Fire Dept.

response.

3.5.3 HHS Fire Response Team Lead Role

The HHS Fire Marshal/Fire Prevention Life Safety Officer is the Fire Response

Team Lead if on site. Otherwise Security takes the lead role. • Assumes control & directs Fire Response Team activities until Fire Dept. arrives. • Obtains info on area & any endangered persons. • Meets and briefs Fire Dept. on arrival, directs them to the scene and provides all

necessary keys (access and elevator control), and HHS two-way radios for Fire Dept.

use. • Communicates with Incident Manager & Area Charge Person. • Determines "all clear" status from Fire Dept. & informs Fire Response Team.

3.5.4 Respiratory Therapy:

• Manages & coordinates transportation of oxygen and medical gas supplies in affected

area(s).

3.6 ADMINISTRATION RESPONSIBILITIES

. Site Director or Administration on-call

1. Take on the role as Clinical Lead;

2. Work collaboratively with the Code Red Response Team providing patient care expertise and direction

required;

3. After hours, weekends and STAT holidays the Administrator-on-call shall work collaboratively with the Code

Red Response Team Lead and assume the role of Clinical Lead;

4. Notify Executive-on-call in the event that the Code Red Alarm involved an actual fire and there is/are: Any

injuries; or any physical/property damage; Evacuation is required

5. Upon notification of the incident to the Executive-on-call it shall be determined if the initiation of the

Incident Command Centre is required. Executive-on-call shall take the lead of Incident Manger upon initiation

of the IMS Command or as deemed necessary by the incident.


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Executive Team

1. In the event of a major fire being confirmed by the Manager/Director or Administrator-on-Call, the Executive –on

Call shall be paged or called. A decision will be made at that time if initiation of the IMS Command Centre is

required;

2. Assume the role of Incident Manager during a confirmed fire situation. The Executive has the ability to delegate

this position as the situation warrants.

3. Work collaboratively with Hamilton Fire Department.

HHS IMS Command Structure

The Incident Management System (IMS) is used to manage all codes, emergencies or disasters. It

includes the following functions in separate or integrated roles depending on the available resources at the

time:

Incident Commander/Manager role · Oversees coordination & overall management of the emergency/disaster response &

recovery; · Organizes & directs the Emergency Operations Center (Command Center or Command

Post) & IMS role assignment; · Chairs IMS command meetings; · Organizes debriefings & identifies areas for improvements.

Operations Chief role · Organizes, directs & oversees the Operations Section i.e. Treatment areas,

Patient areas, Tracking, Facility Operations and Support Services; · Implements the action plans directed by the IMS Command Team.

Planning Chief role · Organizes, directs & oversees the Planning Section i.e. provision of situation analysis,

long-range & contingency planning, resource analysis & planning, data collection &

analysis, identification of technical specialists/experts, recovery planning and

documentation;

Logistics role · Organizes, directs & oversees activities associated with obtaining resources

(staffing, supplies, equipment, facility) & maintaining the physical environment/facility

necessary to support implementation of the action plans. Logistics includes Nutrition,

Materials/Supplies, Equipment, Sanitation/ Housekeeping, Transportation/Portering &

the Labour Pool.

Finance & Administration role · Organizes, directs & oversees activities related to monitoring & tracking costs

associated with the event & implementation of the action plans it include Costs,

Compensation/Claims and Time/Payroll.


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While the IMS Command Team can meet anywhere, in events where communication with internal/external areas is critical, the Emergency Operations Center (EOC), also known as

the Command Center, is activated. It is located where the IMS Command Team converge

to oversee an event, develop/review the situation, issues and strategies for its management

& recovery. In a multisite emergency or disaster, there is both a Central EOC & Site EOCs.

All duties and responsibilities will be fulfilled on a 24/7 basis utilizing onsite personnel and on-

call fan-out protocols.

4.0 Fire Response (In Case Of Fire)

4.1 REACT

On Discovering Fire or Smoke – Don’t Panic

R Remove all room occupants Patients, visitors, or staff must be removed to a safe

distance from the fire of origin horizontally on the same floor through at least one fire separation door.

E Ensure room doors shut. That the doors and windows to the room of fire origin are

closed, leaving lights on

A Activate Fire Alarm. Pull the nearest fire alarm pull station

C Call 5555 (switchboard) Confirm Code Red, and your Location,

T Try and Extinguish fire if possible if you have been trained to do so with appropriate

firefighting equipment. Check the exterior of the door and frame for heat before re-entering the room. Always try and fight a fire in a Team of Two both armed with an extinguisher. If you have the slightest doubt, stay out and concentrate your efforts on evacuating patients.

Smell of Smoke

5555 is to be called for all and any untraceable burning smells

If you see visible smoke or fire – REACT accordingly


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4.1.1 First Stage Alarm: Staff, Patients, Visitors

4.1.2 Second Stage Alarm – Evacuation:

On notification, Staff in Evacuating Area… Assemble in area code staging location Receive & complete assigned tasks & report updates to ACP Prepare patients for evacuation Remain calm, walk rapidly, but do NOT run. Reassure patients & visitors, & in a calm manner quickly

evacuate them from the area. Keep movement on right side of corridors & stairwells to avoid blockage Check patient condition and emotional health periodically

When teams no longer needed, ACP will direct unit staff to the evacuation destination to help care for

evacuated patients & release other staff to return to their home base.

Do not leave until released from duties by ACP On arrival to destination area follow direction of receiving ACP or delegate

Refer to Appendix A: HHS Code Green & H.E.A.T for amplifying information


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4.2 Types of Fires and Extinguishers

An easy way to remember how to use a fire extinguisher is to apply the P.A.S.S. acronym. P – Pull the extinguisher handle pin. A – Aim the hose of the extinguisher at the base of the fire. S – Squeeze the extinguisher handle. S – Sweep the extinguisher hose side to side to ensure full fire extinguishment. This procedure and extinguishment should only take 5 – 10 seconds to complete.

Blankets

These are extremely valuable for use as an improvised fire extinguisher to smother a fire or wrap

around a person whose clothing has ignited.


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4.3 Fire hose

Fire Hoses are restricted to trained persons only

4.4 When to Fight a Fire – Ensure Alarm has been Activated First

Fight the fire only if all of the following are true:

• the fire is small and confined to the immediate area where it started (e.g. waste basket, electrical appliance, couch cushion etc.)

• you can fight the fire with your back to the door at all times

• your fire extinguisher is rated for the type of fire you are fighting and it is in good

operational condition.

• you have had the required training in the use of fire extinguishers and are confident that

you can operate it effectively.

• If possible fires should be fought in teams of two with both staff members armed with

their own extinguisher.

If you have the slightest doubt about whether or not to fight a fire then: Get Out and Stay Out, closing and sealing the door behind you.

FIRE EXTIGUISHMENT, CONTROL /CONFINEMENT Fire Extinguishment

Fire Extinguishment is primarily the responsibility of the Fire Department. The production of toxic fumes within the building makes firefighting potentially dangerous, particularly if a large amount of smoke is being generated. Only after ensuring that the alarm has been raised and the Fire Service notified, a small fire can be extinguished by a trained person(s) familiar with an fire extinguishers operation.

5.0 Fire Safety for Occupants

5.1 Staff Responsibility

It is the responsibility of all personnel to read and be familiar with the procedures and

protocols to be followed in the event of fire or other emergencies. All personnel are to follow

the instructions of, and cooperate with the requirements of the Ontario Fire Code, Ontario

Building Code, Corporate and area-specific Code Red Protocols and Procedures.

All personnel are responsible to ensure that they know the following: • the location of fire extinguishers; • the class / type of fire each extinguisher is designed to extinguish; ; • the location of the fire alarm pull stations and how to operate them; • the location of exits; • that all staff participate in the monthly code red drills and reviews; • the procedures to follow in the event of a fire as directed in the Corporate and their

Area-specific Code Red Orders; • the location of designated area-specific assembly areas to report to when evacuating

the building;


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• that all fires are reported regardless of size of fire or whether or not it has been

extinguished; • that it is a serious offence to tamper in any way with fire and life safety equipment,

including smoke detecting devices and fire extinguishers; • when fire and/or life safety hazards are observed they are reported immediately to your

supervisor; • fire prevention measures appropriate to your work environment; and • inform your supervisor if you require special assistance to evacuate the building.

5.2 Occupant / Staff Training

All personnel working within buildings of the Hamilton Health Sciences are instructed by their supervisors as to their individual responsibilities for general fire safety of the building and its occupants as follows:

All new employees attend a Corporate Fire Safety Orientation session. A copy of Corporate and area-specific Code Red procedure are available on HHS Emergency Disaster Management Site to read and they are also briefed by their supervisor as to:

the location of fire alarm pull stations, fire exits and fire extinguishers within and adjacent to their place of work;

every staff/affiliate member of HHS buildings is responsible to review Code Red monthly:

the location and contents of the Corporate and Area-specific Code Red protocols and procedures;

fire prevention measures appropriate to their work environment and;

complete a on line eLearning of Fire Safety Training session (annual)

6.0 Fire Hazard Control

6.1 Building Decorations

• Only fire retardant/flame resistant decorations and decorating materials can be used in HHS

buildings.

• Open flame decorations, such as candles and sparklers are not permitted

• Exits must be maintained free of obstructions and are used for no purpose other than exiting.

• Fire retardant chemicals must not be used on decorative materials (Because it is virtually impossible

to attain an acceptable degree of fire retardant using fire retardant chemicals on paper and most

other materials)

• Fire retardant chemicals applied at point of manufacture only are acceptable.

• Natural Christmas trees, tree boughs and hay bales are not permitted in HHS buildings.

• Decorations must not be placed on or within one meter (3 ft.) of electrical lamps, heating appliances,

heating piping, etc.

• Decorations should not be hung on doors or door casings • Decorations should be hung up out of

reach.

• Decorations should not be hung from ceiling tiles or their supporting tracks. This may impact on fire

separation barriers, and create pathways for smoke migration.

• Fire hazards such as straw and/or hay are not permitted inside HHS buildings.


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• Electrical lights - used for decoration must be of an approved type and must pass inspection by HHS

electricians.

• Check each string of lights for broken or cracked sockets, frayed or bare wires and loose connections

• Decorative (Christmas, Halloween etc.), lights should only be used in common areas, and installed

in such a way as to eliminate fire and/or tripping hazards. This type of decoration should not be

installed in patient rooms. • Flashing or blinking type lights should not be used anywhere. This type of lighting has been

known to bring on seizures in certain patients.

• Avoid purchasing electrical decorations, extension cords and power bars from “dollar stores”. These

items have been known to be counterfeit and are dangerous as they may not meet Canadian Safety

Standards

6.2 General / Personal Housekeeping

Rubbish and waste material Contribute too many fires and are frequently classed as fire hazards. Except in cases of

spontaneous ignition, they do not actually cause the fire but they can furnish the fuel that is

easily ignited by small sources of heat and allow the fire to spread quickly.

Maintenance of a high standard of housekeeping is essential in the prevention of fire.

Indoors Proper and regular disposal of waste paper and other combustible material is important. At

the end of each work day, waste material is removed from the building and deposited in the

bulk containers provided.

Outdoors Cleanliness and good housekeeping are just as essential outdoors, therefore, rubbish and

waste materials is not allowed to accumulate.

Oily Waste Oily waste, oily clothing, wiping rags, and other materials that are contaminated with

flammable or combustible liquids are subject to spontaneous ignition, and are required to

be stored in an oily waste can bearing the label of the Factory Mutual Laboratories. The

oily waste cans are to be emptied at the end of each working day and the oily waste

removed from the building and stored in metal containers.

6.3 Storage, Handling And Use Of Flammable Liquids

This section applies to the storage, handling and use of flammable liquids in portable

containers inside buildings.

Copy of the Code Brown Spill Procedure to be posted in areas that handle or use flammable

or combustible liquids. See Appendix D


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Flammable liquids are those having a flash point below 100 deg. F, such as gasoline, alcohol and acetone.

Storage Precautions for Flammable Liquids

Additional requirements are necessary for the safe storage and use of liquids that have one

or more of the following properties: • unusual burning characteristics;

• subject to self-ignition when exposed to air;

• highly reactive with other substances;

• subject to explosive decomposition; and

• other special properties that indicate a need for special safeguards.

Under Section 4.1.7.6.(1) of the Ontario Fire Code all Recirculating Ventilation Systems

(Fume hoods), require that a fail-safe vapour detection and alarm system be installed to

continuously monitor the flammable vapour concentration in the exhaust air. The Faculty of

Health Sciences has installed “Ventalert” systems in the University laboratory’s in

compliance with the Code. Information on this system and is available from MUMC

Engineering Services.

• flammable liquid containers and storage cabinets are not stored near exits, stairways or

other areas normally used by and for the safety of personnel.

• storage facilities are approved by the HHSC Fire Prevention & Life Safety Officer and/or,

if required, the Fire Prevention Bureau of the Hamilton Fire Department.

• where required for ready use, quantities of flammable liquids not exceeding the

quantities allowed by Section 4 of the Ontario Fire Code, may be stored in buildings.

• storage is in approved containers and placed in labeled metal flammable liquids storage

cabinets indicating that no smoking or open flames are permitted in the area.

• flammable liquids in quantities exceeding the quantity allowed for ready use by Section

4 of the Ontario Fire Code, are to be stored only in approved compounds or specially

designed rooms or buildings.

Handling of Flammable Liquids

• the dangers associated with dispensing and handling of a low flash point liquid are

brought to the attention of all concerned by the area supervisor. • flammable liquids are not handled, drawn or dispensed where flammable vapours may

reach a source of ignition; • due to the volatility of low flash point flammable liquids, extreme caution must be

undertaken when dispensing liquids from one container to another or refueling

lawnmowers, hedge trimmers, etc. • refueling is not done inside the buildings

• flammable liquids having flash points below 100 deg. F are not used as a cleaning

solvent.


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6.4 Open Flame Hazards Control

A WELDING / HOT WORK permit is required for all cutting and welding and/or use of open

flame.

Staff engaged in HOT WORK will ensure that a fire extinguisher is available and instantly accessible at all times.

6.5 Unobstructed Access to Exits – Clear Corridors Equipment and Carts Corridors must be kept free and clear of all items and equipment except for in use (physically manned) equipment. The only acceptable items that are permitted within the Patient Care Ward corridors are: manned/in use Medication Carts, Cleaners Carts and Patient lifts. All other equipment including Lifts, Medication and Cleaners Carts, when not in direct use, shall be removed from the corridor and stored safely within a room.

Patient Emergency Rest Stations (Chairs)

Patient emergency rest station chairs shall remain in the upright – closed position when not in use.

6.6 Electrical Equipment And Appliances

Electrical Equipment

• is installed and maintained in accordance with requirements and standards of the Electrical Code and applicable construction engineering technical orders.

• electrical equipment and appliances are of a type approved by the Canadian Standards

Association (CSA), Underwriters Laboratories of Canada (ULC), Factory Mutual (FM),

Underwriters Laboratories Inc. (ULI). • installation and maintenance of electrical wiring, equipment and appliances is not

carried out by personnel other than authorized HHSC electricians and technicians or

competent electrical contractors approved by HHSC.

Appliances

• privately owned electrical appliances are of an approved type (see: electrical equipment

and appliances section above). • it is the owner’s responsibility to ensure that all appliances are operated safely and

maintained in good electrical and mechanical condition. • electrical kettles are equipped with an automatic shut off feature.

6.7 Extension Cords

• only approved flexible extension cord sets are used • the cord is not permitted to carry more than its rated current carrying capacity. • extension cords are not to be supported by staples nor looped or tied around metallic

objects such as nails, metal pipes, etc. • extension cords are maintained in good condition without cuts, frays or kinks and are

maintained as manufactured without alteration of any kind.

• Flexible extension cords must never take the place of permanent wiring; they are not

designed or intended for permanent installations


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• Once the task has been completed, the cord should always be disconnected and properly

stored away for future use

Hazardous Locations Only wiring, equipment and appliances approved for use in a hazardous locations are used

for that purpose.

6.8 Portable electrical Heaters

Portable space heating devices shall be prohibited in all health care occupancies unless both of the

following criteria are met.

1. Such devices are used only in nonsleeping staff and employee areas. 2. The heating elements of such devices do no exceed 212F.

Only electrical portable heating devices with an engineering approved sticker are allowed to be used in

the hospital. When authorized for use the manufacturer’s recommendations for operation must be

followed.

Heaters must be CSA, ULC or UL approved

Heaters must have an auto shut off if tipped over, and thermostat and overheat protection.

Heaters must be kept at least 1M (3 feet) away from combustible material.

The heaters must be kept out of the exit routes.

Never plug a heater into a power bar.

Never use a heater with a damaged electrical cord.

Heating element must not be exposed

Heater should be plugged directly into appropriate receptacle

Heater must never be left unattended

Heaters must be turned off when leaving the room.

The total number of portable space heaters deployed within any given floor area must be minimized so as

not to overload the electrical circuits. Overloading the circuits may trip the breakers, which could mean a

temporary or total loss of power to the Area.

Recommended Unit Type: Ceramic or Oil Filled

If you use space heaters use them with care.


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7.0 Fire Safety Maintenance Regulations Ontario Fire Code

Before working on the Code Red fire system the occupants of the building must be notified that

maintenance is being preform on fire system and staff are to call 5555 if there is smoke or fire.

When any life safety system is under test, repair or shutdown, Facilities Management shall notify the alarm-monitoring agency advising them of the situation and not to initiate communication to the Hamilton Fire Department should an alarm condition be received.

The Switchboard operator will also announce overhead via the paging system that the fire alarm system is being tested.

Should a fire start while the test or drill is being conducted, Switchboard shall be notified as per the normal REACT procedure and it will be the responsibility of Switchboard to call the Fire Department advising them of the actual fire situation;

During any shutdown of fire protection equipment and systems for part thereof, the Security shall provide hourly rounds of the affected areas. This shall be evidenced by a log book recording these hourly rounds

Engineering - Fire Safety Maintenance Requirements

Definitions:

Check means a visual observation to ensure the device or system is in place and is not obviously

damaged or obstructed.

Inspect means physical examination to determine that the device or system will apparently perform in

accordance with its intended function.

Test means operation of device or system to ensure that it will perform in accordance with its intended

function.

Owner means any person, firm or corporation controlling the property under consideration

Chief Fire Official means the municipal Fire Chief or a member of the Fire Department designated by

him or, where there is no fire department, such assistance to the Ontario Fire Marshall as the Fire

Marshall may designate for the municipality or territory without municipal organization.

DAILY 1. Check Exit signs to ensure they are in a clean and legible condition 2. Check Exit lights to ensure they are illuminated and in good repair 3. Check Torches, regulators and welding equipment for defects 4. Check Fire alarm system AC power lamp and trouble light 5. Check Central alarm and control facility 6. Check Tank heating equipment, enclosure and water temperature for fire protection water tanks

during freezing weather. 7. Check Temperature of fire pump rooms during freezing weather.


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WEEKLY 1. Check hoods, filters and ducts in ventilation systems subject to accumulation of combustible deposits 2. Check that sprinkler system control valves are open 3. Check that dry pipe sprinkler systems air pressure is being maintained 4. Inspect valves controlling fire protection water supplies 5. Check the water level and air pressure for fire protection systems pressure tanks 6. Inspect relief valves on air and water supply lines of fire protection system pressure tanks 7. Check water level in fire pump reservoirs 8. Inspect and operate all fire pumps*

Check all components of emergency generator system and operate the generator set under at least 50%

of the rated load for 30 minutes *

Test maintain emergency power systems as per CSA-C282

MONTHLY 1. Inspect all doors in fire separations 2. Inspect and test emergency lighting system, batteries, units and lamps * 3. Conduct fire alarm drills for supervisory staff in day care centers and health care facilities 4. Test all, welding and cutting equipment * 5. Inspect all portable fire extinguishers (as per NFPA 10-1990) 6. Test the fire alarm system and check all components including standby batteries * 7. Test the voice communication system * 8. Inspect all fire hose cabinets 9. Test the sprinkler alarm * 10. Inspect the water level in gravity fire

EVERY 2 MONTHS 1. Test sprinkler system central station connections *

EVERY 3 MONTHS 1. Test all fire safety devices in high buildings as defined by subsection 3.2.6. of the Ontario Building

Code 2. Test fire fighters elevator for proper operation. 3. Inspect the priming water level for dry pipe systems

EVERY 6 MONTHS 1. Inspect fire protection systems for commercial cooking equipment * 2. Test gate valve supervisory switches and other sprinkler and fire protection system supervisory

devices * 3. Check and clean crankcase, breathers, govenors and linkages on emergency generator sets 4. Inspect and maintain special extinguishing systems 5. Inspect elevators in an elevator shaft that is intended for use as a smoke shaft and ensure they

function as designed under an alarm condition *


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ANNUALLY 1. Inspect all fire dampers and fire stops flaps 2. Inspect all chimneys, flues and flue pipes 3. Inspect disconnect switches for mechanical air conditioning and ventilation systems. 4. Clean chimney spark arresters 5. Check smoke alarms shall be maintained in operating condition by the owner 6. Conduct maintenance procedures for fire extinguishers. 7. Test fire alarm system by qualified personnel acceptable to the Chief Fire Official (as per CAN/ULC

S536 M97) * 8. Conduct a complete test of the voice communication system by qualified personnel acceptable to the

Chief Fire Official * 9. Inspect all standpipe hose valves 10. Remove and re-rack all standpipe hose 11. Inspect all exposed sprinkler system pipe hangers 12. Inspect all sprinkler heads 13. Inspect dry pipe water priming level 14. Inspect fire department connections 15. Conduct sprinkler system alarm test using the most hydraulically remote test connection * 16. Conduct a dry pipe system trip test * 17. Conduct a main drain flow test of the sprinkler system water supply * 18. Inspect fire protection water supply tanks 19. Inspect the cathodic protection of steel fire protection water tanks 20. Inspect all parts of a gravity fire protection water tank 21. Conduct a fire pump flow test 22. Inspect and flow test all fire hydrants 23. Conduct general engine and generator maintenance and engine tune-ups for emergency generator

sets 24. Inspect closure at the top of air-handling used for venting 25. Test smoke control equipment

EVERY 2 YEARS 1. Check all steel fire protection tanks for corrosion 2. Inspect all fire protection water supply tanks, connected to a non-potable water supply, for the

accumulation of sediment. 3. Check valve adjustments and torque heads for emergency generator engines

EVERY 3 YEARS 1. Clean and service injector nozzles and check valve adjustments for emergency generator diesel

engines

EVERY 5 YEARS 1. Hydrostatically test carbon dioxide and water type extinguishers* 2. Hydrostatically test dry standpipe system * 3. Inspect fire protection water tank connected to a portable water supply, for the accumulation of

sediment 4. Check insulation of generator windings 5. Inspect closures in vent openings into smoke shafts


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EVERY 6 YEARS 1. Replace the extinguishing agent in dry chemical fire extinguishers

EVERY 12 YEARS 1. Hydrostatically test dry chemical and vapourizing liquid fire extinguishers*

EVERY 15 YEARS 1. Inspect dry pipe sprinkler systems for pipe obstruction - flush the system when necessary

AS REQUIRED 1. Check doors in fire separations to ensure they are closed 2. Check lint traps in laundry equipment 3. Ensure streets, yards and private roadways that are provided for fire department access are kept

clear 4. Check corridors and ensure they are maintained free of obstruction 5. Clean any combustible dust producing operations 6. Clean residue in spray booths 7. Vacuum clean and dust any dry powder finishing operations 8. Inspect, clean and maintain all industrial ovens and associated duct work 9. Inspect sprinkler system auxiliary drains 10. Maintain smoke control equipment in a manner to ensure satisfactory operation 11. Inspect and Test all equipment used in conjunction with smoke control measures * 12. Inspect and Test all equipment used in conjunction with smoke control systems *

* THESE ARTICLES REQUIRE WRITTEN RECORDS TO BE MAINTAINED

NOTE: WHENEVER A DEFECT OR DEFICIENCY IS DISCOVERED IN ANY FIRE AND LIFE SAFETY EQUIPMENT, AS A RESULT OF THESE MAINTENANCE REQUIREMENTS, CORRECTIVE ACTION MUST BE TAKEN IMMEDIATELY. DURING ANY SHUTDOWN OF FIRE PROTECTION EQUIPMENT AND SYSTEMS OR PART THEREOF, THE ELECTRICAL

SUPERVISOR OR DESIGNATE WILL ARRANGE WITH HHS SECURITY FOR HOURLY ROUNDS OF THE AFFECTED AREAS TO BE CONDUCTED. A LOG BOOK RECORDING THESE HOURLY ROUNDS IS TO BE MAINTAINED. THE PERTINENT INFORMATION

REGARDING SYSTEMS SHUT DOWN WILL BE COMMUNICATED TO THE HAMILTON FIRE

DEPARTMENT DISPATCH AT (905) 546 – 3333 ext. 6. Before and After System Shut Down

Alarm system down for maintenance signage to be posted at the primary site entrances


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Appendix A

HHS Code Green Response Procedures for evacuation and evacuation of persons needing assistance


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HHS Code Green Response Plan

Area Charge Person (ACP) Determines need to evacuate area/unit

Calls Switchboard x5555 (x7777@ SPH) (x400@WLMH)

Identifies site, code, exact location, evacuation destination & if H.E.A.T.

(Hospital Evacuation Assistance Team) assistance needed

Switchboardo Notifies Site Dir./Dir on-call/SAM & others on notification listo Announces x3 code on overhead/paging +H.E.A.T. activation o Follows Incident Manager direction

Is situation contained?Yes No

Incident Manager (Site or Director on Call)o Ensures Manager, Director, Medical Lead of affected area notifiedo Determines need to activate Command Center in consultation with

Site or VP on-callo Determines need to further escalate Code Green to Standby or

In-Effect for specific floors, wings or building & directs evacuation sequence (see Appendix B for Building Evacuation)

o Notifies Switchboard to announce Code Green Alert, Standby, In-Effect or All Clear as appropriate.

On “All Clear” notification… Areas not impacted resume normal duties. Areas impacted (e.g. evacuated or in refuge areas) await direction from Incident Manager on how to proceed/

resume operations/services

Updates Incident Manager of evacuation status

On announcement of a (Controlled) Code Green Standby... Areas prepare pts & staff for evacuation.On Command Center direction... Evacuating In-Patient Care Area(s): 1. Print & complete Patient Evacuation Worksheet for each inpt.2. Submit Worksheet to designated staff to collate info on hardcopy of Code Resource Status Report & submit info via online Code Resource Status Report to Command Center to coordinate support.Evacuating Out-Patient Care Area(s): 1. Print & complete Patient Evacuation Worksheet for any outpt unable to leave bldg immediately (e.g. needs pick up by next of kin)2. As aboveAll Other Pt & Non-Pt Areas (e.g. Support & Admin. Depts):1. Complete & submit online Code Resource Status Report based on ability to deploy resources (staffing, equipment, supplies) to assist evacuating area(s). This information is reviewed by the Command Center to coordinate distribution of resources to evacuating areas.For Code Green (Controlled) In-Effect …Command Center will notify & direct evacuation of areas in specific sequence based on risk & need & request completion of online Bed Status Report &/or Pt Evacuation Location Status Report as needed.

Security (or designate @WLMH) o Go to scene to assess &

provide assistance (if able)o Meet & escort external

emergency response team o Notify Parking to put parking

gates in “up” position (if applicable)

o Activate Access Control Officers to keep key entrances clear & help control traffic flow

o Manage external Hospital emergency access routes

o Liaise with Command Center/Incident Manager

Follows Code Green STAT Action Checklist (see p2)

On discovery of an immediate & serious hazard to occupants of a room or area… Staff: Immediately remove all occupants from room of origin first, then adjacent & opposite rooms; proceed to nearest safe, staging area & notify the Area Charge Person (ACP) for further direction


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CODE GREEN–STAT Action Checklist

On discovery of an immediate & serious hazard to occupants of a room or area

in…

Out-patient Care areas (incl. Physician office areas) or

Non-Patient Care areas (e.g. Support & Administrative Depts.)

Assemble & account for all occupants; proceed to assembly area (Cafeteria) to

await further direction from Incident Manager

IN-PATIENT Care areas…

On discovery of an immediate & serious hazard to occupants of a room or

area...

Staff: immediately remove all occupants from room of origin first, then adjacent &

opposite rooms & proceed to nearest safe, temporary staging area & notify the

Area Charge Person for further direction.

On notification, Area Charge Person (ACP) in Evacuating Area:

1. Put on ACP vest;

2. Ensure all occupants are cleared from immediate danger & accounted;

3. Determine risk & extent of evacuation necessary, evacuation route &

destination. Evacuate everyone to the same destination if possible to

facilitate tracking of occupants & equipment

4. Assemble all staff to quickly debrief, disseminate action plan & assign staff

tasks & establish teams

a. Determine #of staff available & additional staff needed to assist with

evacuation based on patient census & mobility. Calculate & delegate:

2 staff to escort groups of 6-8 ambulatory patients;

1 staff per patient in wheelchair or 2 if using rolling office chairs;

4 staff per patient in bed or stretcher;

2-4 trained staff per resistant patient (e.g. Fire Response Team or Fire Dept)

or for isolation patient (e.g. trained staff with PPE)

b. Prepare patients for evacuation:

For Ambulatory patients- have staff instruct ambulatory patients put on

coats & shoes, take assistive devices (e.g. glasses, hearing aids, dentures) &

line up outside their rooms with their bed blankets wrapped over their

shoulders The Escort Teams will collect them in groups of 6-8, instruct them

to form a chain by holding hands or placing their hand on the shoulder of the

person in front of them & following the lead staff escort to the destination

area. The second staff escort follows at the end of the line to ensure no one

is lost and to identify any problems. Blankets are both for comfort & as a

means of transport if patients become non-ambulatory & need to be pulled

on the blanket.


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For Wheel chair patients- if rolling office chair used, ensure chair is pulled

not pushed with second staff person keeping patient’s legs off floor using belt

or bed sheet.

For Bedridden pts - move only critical pts with beds. If authorized to use specific

elevators, first move critical & bedridden pts

For those resisting to leave notify Fire Response Team or Fire Dept. to

assist

c. Establish Staff Evacuation Teams

i. Transport Teams for Ambulatory, Wheelchair & Bed/Stretcher patients;

ii. Corridor teams in key areas to clear corridors, doorways/exits & form a

brigade for horizontal transport of patients to destination

iii. Carrying Teams in stairwells for vertical evacuation if applicable;

iv. Oxygen Teams for collecting & distributing portable oxygen, ventilators &

ambu bags;

v. Equipment Teams for collecting & distributing wheelchairs, office rolling

chairs, Collect & distribute essential evac equipment e.g. wheeled chairs,

blankets etc.

vi. 2 Triage Nurses- one for evacuating area to coordinate sequence of

evacuation (i.e. ambulatory patients first, then wheelchair & finally

patients in beds or stretchers. The other Triage nurse will triage patients

on their arrival in the destination area for further transfer (e.g. ICU, ER) or

treatment of injuries

vii. 2 Trackers- one at exit of evacuating area and one at entrance of receiving

area who account for all occupants & identify if anyone missing;

viii. Support Teams who collect and move any needed supplies in bulk (e.g.

charts, kardexes, medication administration records, Medication carts)

ix. 2 Room Checkers who check rooms after emptied for stragglers, close &

tape doors at knee level. They check closets, washrooms, & under beds,

etc., where a frightened or disoriented person might hide.

5. Call 5555(7777@SPH) to report situation, site, code location, evacuation

destination location & if H.E.A.T. (Hospital Evacuation Assistance Team)

assistance required

6. Notify receiving area of situation & identify meeting point to receive patients

7. Ensure all rooms are vacated & taped & tape corridor doors when leaving.

8. Take all keys (include med keys), copy of patient & staff census

9. On arrival, confirm head count & update Command Center of status & any

needs/issues

10. Assign staff to care for patients based on acuity; release other staff to return

to home base


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IF EMERGENCY REQUIRES EVACUATION OUTSIDE BUILDING:

Direct all area occupants to assemble outside in an orderly fashion away from

an exit or fire hydrant

Ensure everyone is accounted for & notify Command Center if someone is

missing

Assign a Runner to update Command Center

Instruct staff to remain with their groups, assess & comfort patients & await

further direction from Command Center to move patients to emergency

transport or external triage / transfer point.

Triage & identify critical patients for first available transfer;

Unless directed to do so, do not re-enter an affected area until the “All Clear” is

given.

On notification, Staff in Evacuating Area…

Assemble in area code staging location

Receive & complete assigned tasks & report updates to ACP

Prepare patients for evacuation

Remain calm, walk rapidly, but do NOT run. Reassure patients & visitors, & in a

calm manner quickly evacuate them from the area.

Keep movement on right side of corridors & stairwells to avoid blockage Check patient condition and emotional health periodically

When teams no longer needed, Area Charge Person will direct unit staff to the

evacuation destination to help care for evacuated patients & release other staff to

return to their home base.

Do not leave until released from duties by ACP

On arrival to destination area follow direction of receiving ACP or delegate

Area Charge Person in Receiving Area…

Put on vest & assemble staff & debrief

Organize staff to receive incoming patients, clear corridors/exits, rearrange

rooms/space

Staff in Receiving Area… Assemble in area code staging location Receive & complete tasks to make room for incoming patients (e.g. clear corridors/exits,

rearrange rooms/space)

Applies to: All HHS staff, affiliates & members of the medical & midwifery staff

1.0 Purpose: To outline the procedure to follow for a safe partial or total evacuation of a Hospital

area, wing or building.


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2.0 Code Green Definitions

Code Green Alert is announced when information indicates an evacuation is possible, but not

yet confirmed & additional investigation/information is needed for any response activation.

Code Green STAT is implemented when immediate evacuation of all persons from an area of

clear & present danger to one of safety is needed. It is activated only in situations that pose a

clear & immediate hazard to persons in the area.

Code Green is a precautionary & planned evacuation used for situations that may pose a

threat to persons, but allow time to prepare for evacuation. It is based on evacuation

directions from the established Command Center & has two stages: Code Green Standby which requires all staff to return to their work stations &

prepare their area for an eventual but definite evacuation. Code Green In Effect which activates implementation of a controlled evacuation of all

occupants in area(s) identified by the Command Center.

Code Green-All Clear identifies that all areas can resume normal duties. Those areas already

evacuated are to receive specific direction from the Incident Manager/Command Center

2.1 Code Green Notification can occur in various ways: Overhead announcement & page of a

Code Green STAT, Standby or In-Effect with or without the rapid ringing of the fire alarm

bells. The sounding of the evacuation fire alarm bells without additional notification by

overhead, paging, phone or Runner for a Code Green Standby or In-effect is considered a

Code Green Alert in the absence of clear & present danger signs. Staff will always be directed

or notified by the Command Center when to activate a Code Green (Precautionary) response.

2.1 Types of Evacuation

Horizontal Evacuation: entails evacuation of all persons on a floor to a place of safety beyond

2 fire/smoke barrier doors on the same level. It is the first evacuation response before vertical

evacuation is considered. Patient care areas should evacuate to another patient care area so

equipment & health care provider staff are readily available.

Vertical Evacuation: When horizontal evacuation is not possible, evacuation should then

occur vertically always towards ground level in anticipation that exit from the building may be

required. Move patients either 2 levels at a time towards ground level or directly to ground

level exit. If possible, evacuate from the side of the building not affected by the emergency or

used by emergency personnel. Ambulatory patients should proceed down stairwells first,

followed by transport of non-ambulatory patients, applying “keep to the right” rule & using

appropriate lift & carry techniques (see Appendix). Staff should be posted at all stairwell &

exit points to coordinate movement, restrict access & facilitate patient tracking.

TOTAL WING OR BUILDING EVACUATION: ENTAILS

EVACUATING THE WING OR BUILDING IN A CONTROLLED & COORDINATED MANNER DIRECTED BY THE COMMAND CENTER/INCIDENT MANAGER.


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Evacuation Routes: Each area should have two horizontal evacuation routes, one primary &

one secondary route. Primary & secondary evacuation routes should always be in opposite

direction of each other. In some cases, a secondary route may entail traveling down a

stairwell to the outside of the building & re-entry into a safe area.

2.2 General Principles for CODE GREEN (PRECAUTIONARY/PLANNED) EVACUATION • A Command Center delegate will direct the Area Charge Person when to initiate evacuation

(code green in-effect) of the area & the evacuation destination. However, if at any point

the situation changes & safety becomes an issue, the Area Charge Person may implement

a STAT Evacuation of their area. • Only on Command Center direction should staff fan-out or patient decanting (patient

discharge/transfer) processes be initiated; • If evacuation is not immediate & beds are required, patients to be discharged may be

placed in waiting areas in the pt. care are, with continued meals & meds provided until

they are transferred to the Discharge Holding Center (if established) 30-60 minutes before

scheduled pickup; • Ambulance dispatch communication will be coordinated centrally through the Site

Command Center. • In a code green standby, all patients are returned to their home unit if possible. If an

operation or procedure cannot be interrupted, it may be continued at the discretion of the

medical staff person in charge & the home unit notified that the procedure area will take

responsibility for evacuating the patient & relevant documents (chart, kardex, Medication

Admin Record) as needed. 2.3

Authorization for Evacuation & Re-entry

• Evacuation of part or all of the Hospital building is only initiated by a clear & immediate

threat to injury or loss of life following consultation with relevant parties (e.g. Fire, Police). • The decision to evacuate an area in immediate danger is with the area’s Charge Person. • The decision to activate a coordinated, planned evacuation of an entire floor, wing or

building evacuate the entire building is with the Incident Manager of the established

Command Center, who directs the evacuation process & specifies which areas are to

evacuate when & to where. The Incident Manager, in consultation with the appropriate

personnel (e.g. Engineering, Security, Fire, Police), also determines if re-entry is safe &

permits re-entry or identifies other plans.

2.4 Responsibilities

All staff are reminded that in the event of an evacuation, their assistance may be needed to aid in the movement of patients, based on their knowledge & physical capability.

2.5 Order of Evacuation

Evacuation of all occupants is a priority & judgement must be exercised to determine the order

to undertake the tasks involved given the time available & safety involved..

Area specific evacuation is first to a safe assembly area near an exit & as far as possible from

the hazard on the same level. Patients are evacuated horizontally through at least two corridor

fire/smoke barrier doors away from the hazard on the same floor. Once in the safe area, the

evacuation routes & direction of the charge person of that area are to be followed. Horizontal

evacuation can be self-initiated if there is a clear & present danger.


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Planned Patient Evacuation Triage & Discharge Evacuation triage divides patients based on mobility (i.e. ambulatory, wheelchair & bedridden)

& what further care is required (e.g. discharge home +/- CCAC or transfer to other facilities).

Transportation needs are determined as: next of kin car pick-up, bus/DARTS drop-off service or

ambulance. Critical cases needing immediate & constant treatment are transferred first by

ambulance from the ED. Stable stretcher patients needing further care can await transfer via

ambulance in a designated area (e.g. parking lot). Discharged patients are escorted to an

identified Discharge Holding Centre for pick-up by their next of kin. This information is

documented individually & then collated & submitted via the online Code Patient Evacuation

Summary Report for review & direction by the Command Center.

2.6 Interim Staging Location or Meeting Point In evacuation, patient care areas can bring their patients & visitors to a predefined interim

staging location or midway meeting point where patients are passed to receiving area staff who

continue to move the patients to their evacuation destination. However patients & staff in an

immediate crisis area may evacuate directly to their evacuation destination if their Area Charge

Person deems it to be more expedient. The Area Charge Person will identify staff who are to

remain with patients in the new location & those who are to return to help with further

evacuation.

2.7 Elevator Use

• Elevators are only to be used if permitted & manually operated by authorized staff. • When elevator use is permitted, the flow & sequence of elevator evacuation is different i.e.

bedridden patients are moved first, then hose requiring wheelchairs & finally ambulatory

patients. Patients evacuated first should be moved to the farthest location to minimize

congestion. • When elevators are not permitted or not functional, first escort ambulatory patients, then

wheelchair & finally evacuate bedridden patients by whatever means possible (e.g.

Evacusled, blanket drag etc…)

2.8 Continuity of Patient Care & Transfer of Information

In a total planned building evacuation, charts, kardexes & medication administration records are

sent with the patient on transfer to another facility or retained by the designated HHS staff for

discharged patients. A log (in duplicate) of the patient’s name, unit, Most Responsible Physician

& destination is completed at exit from the Hospital by assigned clerical staff. Patients

transferred or discharged will be called back to Hospital as necessary. Admitting staff will update

patient location records on receipt of information & contact patients’ next of kin to inform them

of any facility transfer.

In a planned total building evacuation, time permitting, a Transfer Form (in duplicate) with

patient’s diagnosis & treatment requirements should accompany patients with their health

record, care plan, kardex & medication administration record. Admitting staff will use the copy

to confirm patient arrival at destination.

A tag can be used for any patient needing special handling e.g. patients needing meds within

next 4 hours. The tag should include the time the med is due & is removed after it is given &


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no further medication required. Whenever possible patients’ medications should accompany

patient.

2.9 Equipment Patient beds or equipment are only moved if the patient’s condition requires it. Incubation,

isolettes & other life support systems are moved with the patient if possible. Respiratory Therapy

staff & Porters will transport ventilators & monitoring equipment & ensure they are labeled.

2.10 Visitors

The Command Center will determine if visitors are asked to leave the hospital or remain to

reassure & assist patients during evacuation. This based on the reason for evacuation & safety

issues.

2.11 H.E.A.T. (Hospital Evacuation Assistance Team)

An area evacuating is to identify any need for additional staffing to assist with the evacuation.

This is based on the patient population mobility status, the area’s staffing complement & the

urgency of evacuation. If immediate assistance is critical, the Area Charge Person is to request

Switchboard to announce activation of H.E.A.T. (Hospital Evacuation Assistance Team) & the

area in need.

On hearing the announcement all clinical & non-clinical areas are to deploy one staff member to

the evacuating unit & report to the Area Charge Person there for appropriate assignment. Once

there, staff are to remain on the unit completing assigned tasks until released by the Area

Charge Person.

Staff Deployment Center

In a code green (precautionary) required & available staffing assistance is submitted via

the online Code Resource Status Report. If there is time, a staff deployment center is

activated & the location announced (e.g. cafeteria). When Telecommunications

announces the location of an established Staff Deployment Center, staff who do not have

direct clinical patient care responsibilities & those who have completed their patient care

responsibilities (e.g. outpatient areas) are to report to the designated deployment

location, after securing their area, to be assigned to assist with the evacuation process.

2.12 Area Specific Information for Code Green includes: a) Occupant Tracking Record used (e.g. Staff Attendance Lists or Sign In Sheets; Census or

Clinic record for Patients & Visitors)


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b) Horizontal Evacuation Destination & Interim Meeting Point (for in-pt areas only) e.g.

midway between 2 areas c) Floor plan with primary & secondary horizontal & vertical evacuation routes & exits d)

External Assembly Area

Equipment needed: 2” Masking Tape; Flashlight with batteries; knife/scissors

3.0 Procedure- see Flowchart & Action Checklist

4.0 Developed By Code Green Subcommittee

5.0 Approved By Sr. Management, MAC, PAC, EDM Steering Committee

Lift & Carry Techniques

Use correct lift & carry techniques to ensure proper spine alignment & prevent injury (Keep

Ears over Shoulders & Shoulders over Hips) with available evacuation equipment (e.g.

Weevacs, Evacusleds, Evacu chairs, Stairwell slides) & the following techniques as needed.

Note: This poster is placed in a

visible location by every bed that

has an Evacusled for quick

emergency reference.


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Side-By-Side (semi-ambulatory)

Stand beside pt

Secure pt’s arm around rescuer & hold pt’s wrist or hand if possible

Snug pt close

Walk to a safe area

Grasp the patient’s other

arm if possible

Bear Hug (semi-ambulatory)

Stand behind the person

Place arms under the person’s

armpits

Rescuer’s head should be kept off

to one side

Grasp person’s left and right wrists

Cross the arms in front

Gently prod the person to walk to a

safe area

Cradle Drop (non-ambulatory)

1. Ensure bed wheels locked or move bed against wall & put bed to lowest position

2. Place 2 blankets on floor partially under bed & past head of pt

1. Kneel beside bed with one leg raised closest to pt’s head

2. Grip pt under knees & shoulders 3. Lean back, sliding pt off bed

Cradle Drop (cont’d)

Control pt’s descent onto your lap & then onto floor while protecting head

Do not resist it

Fold blanket around pt Drag pt head first to safe area

Swing Carry (non-ambulatory) Needs 2 rescuers; can be used on stairs

1 st rescuer raises pt to sitting position 2 nd rescuer moves pt’s legs over side of bed One rescuer maintains control of pt at all times to

prevent pt falling to floor

Rescuers sit on each side of pt Pt’s arms placed on rescuer’s shoulders Rescuers secure their arm around pt’s back &

grasp each other’s arm Rescuers pass other hand under patient’s knees

locking hands or wrists

Swing Carry (cont’d) Extremity Carry (non-ambulatory) Needs 2 rescuers; can be used on

stairs

1. Standing between pt’s, 1st rescuer grasps pt’s legs just above ankles or under knees

2. 2 nd rescuer places their arms under pt’s arms & clasps their hands on pt’s chest

3. Both rescuers holding pt firmly lift pt simultaneously & move to safe area

Simultaneously lift pt & move to safe area ) Lowering Technique (

Lower pt to sitting position by kneeling down with leg closest to pt Lower pt from sitting position to lying position while protecting head


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Appendix B

Voice Communication and Building Automation Systems:

As a standard all overhead public announcements will be broadcast via Paging through

Telecommunications at ext. 5555. In the event that Paging is unavailable all systems (alarm,

voice communication and building automation), operational instruction are posted within the

CACF. To augment posted instruction, during a Code Red Fire Alarm the CACF and/or Central

Control Centre are manned by systems trained HHS Electrical Staff to ensure that any required

operational need is conducted in an expedient manner.


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45


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DURING ANY SHUTDOWN OF FIREFIGHTERS’ ELEVATORS, THE PERSON IN CHARGE

WILL NOTIFY ALL SUPERVISOR STAFF. IF THE FIREFIGHTERS’ ELEVATOR IS NOT

OPERATIONAL FOR MORE THAN 24 HOURS, NOTIFY THE FIRE DEPARTMENT BY

CALLING 905-546-3333, OPTION 6 AND NOTIFY ALL OCCUPANTS BY POSTING

ANNOUNCEMENTS OF THE SHUTDOWN ON ALL FLOORS AT THE FIREFIGHTERS’

ELEVATOR. ALSO, THE PERSON IN CHARGE SHALL NOTIFY THE FIRE DEPARTMENT

AND ALL OCCUPANTS WHEN FIREFIGHTERS’ ELEVATOR HAS BEEN RESTORED

Appendix C

3G Child and Youth Mental Health Program (Inpatient Unit, Mental Health Assessment Unit

The 3G Child and Youth Mental Health Programs at McMaster Children’s Hospital include a

locked 22 bed in patient unit, 6 day hospitals spots, a Regional Program and staffing for the

Child and Youth Mental Health Assessment Unit (MAU) in the Emergency Department. Due to

the acuity of the patients (in the locked unit), when the fire alarm is activated Patients are

brought into one of the two lounges (Pts in rooms 7-22 in the North lounge, pts in room 1-6 in the south lounge). The

bedrooms/bathrooms/interview rooms are all checked and when confirmed empty the room is

locked and a piece of tape is put over the door jamb to identify rooms that have been searched.


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If the evacuation is required 3G will evacuate horizontally to room 3E26 yellow quadrant (multiple

pathways of egress to route to 3E26 available). If external evacuation is required the programs

will assemble in the main lounge (south lounge if the main lounge is not accessible) evacuate

through the purple section stairwell, assemble in the back garden and then proceed as a group

into the adjacent University Building

The Unit has specialized key activated pull stations with two keyways.

• One key will activate the first and second stag alarm

• The keyway on the left, labeled “pre-signal” will activate a stage one alarm and also unlock

the door directly adjacent to the activated pull station. Activating the pre-signal keyway at

the pull station by the front door will release ONLY the front entrance door. All other doors

will remain locked. • In the event that a stage one alarm needs to be called but more than one door is required

to be unlocked, more than one pull station may be activated to correspondingly unlock

numerous doors. • The unlocked door will remain disengaged as long as the key is turned to the “on” position

and until engineering resets the locks. • The keyway on the right, labeled “general alarm” will activate a stage two alarm and unlock

All Unit Doors • All doors will remain unlocked until the doors are re-engaged by security/engineering

All staff will have a pull station key in their possession at all times

Security will escort the Fire Department to 3G with keys.


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CAF (Central Animal Facility – 1U) controlled access area The CAF follows the standard HHS

Code Red Emergency Response Protocols. All Secured doors will release if the alarm point is located

within the Facility or within the CAF Quadrant - Red/Yellow quadrant. All doors are also automatically

released in a Stage Two Alarm. All Fire pull stations are of standard design and operation. All Exit doors

are clearly signed “Emergency Exit Door Released by Fire Alarm”.


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Appendix D

Code Brown


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YesNo

Staff activate Code Brown i.e.

q Remove occupants from spill area

q If safe & able, identify & contain spill

q Secure & restrict access to spill area with tape

q Call x5555 (x7777@SPH)(x400@WLMH), state site,

location, Code Brown & spill type i.e. chemical, biomedical-blood/cytotoxic or radioactive; spill location (area, room #). Leave name & ext. for additional contact

q Notify Area Charge Person who informs Manager/Supervisor

q Obtain & review Material Safety Data Sheet

q Wait for direction from IM based on spill type (see below)

Telecommunications

q Announces code brown & location overhead x3

q Contacts those on notification list based on spill type

q Notifies others as directed by Incident Manager

q Updates those involved in spill response of code status

Engineering if directed by IM...

q Shut ventilation or switch to total exhaust for

spill area

q Shut mechanical/electrical systems

q Respond to spill location to assist once air

handling system controlled

IM HSW for

chemical or

unkown spills

IM IP&C

for biomedical

(blood) spills

IM Pharmacy

for cytotoxic

spills

Code Brown “All Clear” paged

Code Green Standby or In-Effect announced & paged

q Staff do not call Code but

proceed with spill clean-up* & appropriately dispose of waste

q Complete & forward

Safety Occurrence Report* Dept causing spill is responsible for

actual spill clean-up regardless of location

Legend:IM= Incident ManagerIP&C= Infection Prevention & Control MOE= Ministry of EnvironmentHSW= Health Safety Wellness

Manager/Supervisor of Spill Area

q Ensure exposed staff, pts & visitors are

escorted to receive medical attention, Complete occurrence report & forward to relevant parties incl. EDM

q Arrange for incident stress management

for those involved as needed

q Ensure completion of any follow-up

activities e.g occurrence report; debriefing meeting

Security

q Respond to spill location

q Ensure area secured

q Meet & escort external spill

response company, if notified, to spill area

Incident Manager (IM)-HSW, IP&C, Pharmacy or Radiation Safety Officer...

q Act as Incident Manager or assume joint command with Site Director/Director on-Call or delegate

q Phone affected area to determine: nature & volume of spill, affected persons, potential hazards to life,

environment & property, if internal clean-up can proceed with direction or if external spill company required for clean-up (if latter, collaboration with Director/VP on-Call needed)

q Direct Telecomm to notify/update others as needed

q Review management of spill and requests follow-up as needed

q Advise Telecomm of “all clear” or Code Green status

Customer Support Service (CSS)notified only after spill

cleaned & safe for final rinse

HHS Code Brown Summary Checklist

IM Radiation

Safety Officer for radioactive

spills

or

Waste Management Coordinator notified if spill enters natural environment (e.g.

sewers, soil) for MOE & City notification

Staff observes or discovers hazardous material spill...

q has knowledge, skills & equipment to correct spill

situation safely

q able to handle size of spill

Staff discovers spill of

unknown or suspected

hazardous material in

an unstaffed area

Note:External spill company is

Quantum Murray @ 1-877-378-7745)

Note:Site Director/Director On Call to report spill to Ministry of Environment and City of Hamilton when WMC is out of office.


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1.0 Purpose

To define the response for an internal hazardous material spill that staff are unable to manage safely

in so as to protect the health & safety of patients, staff & visitors & to mitigate any adverse impact on

the facility or surrounding environment.

2.0 Equipment

Caution/masking tape & area specific spill kit (if applicable)

Appropriate PPE based on the hazard

3.1 Policy

The main purpose of the provincial WHMIS legislation is to require employers to obtain health and

safety information about hazardous materials in the workplace and to pass this information on to

workers. While most spills are handled without the need for external assistance, HHS recognizes that

not all spills can be safely cleaned up without additional advice, equipment or external assistance.

3.2 Code Activation

Staff are to call a code brown when they do not feel they have the knowledge, skills or equipment

necessary to correct a hazardous material spill (i.e. Chemical, Biomedical/Blood, Cytotoxic or Radiation

spill) safely or if staff cannot handle the size or nature of the spill. This includes a spill discovered in an

un-staffed area or any uncontained cytotoxic spill that occurs in the Chemo Suite/Pharmacy at the JCC

that cannot be covered with one chemotherapy prep pad (25cmx30 cm). See Addendum-JCC Chemo Suite

Use of Ventilation Switch in Code Brown.

3.3 Code Notification

Code Brown is paged overhead to ensure staff avoid the code area and via pager to the appropriate

areas for response i.e. HSW for chemical spills, Infection Prevention & Control for biomedical/blood

spills, Pharmacy for cytotoxic spills & Nuclear Medicine Radiation Safety Officer for radiation spills.

3.4 Payment for External Spill Response Company

As the department or program responsible for the cause of the spill is responsible for clean-up, they

are also accountable for costs associated with spill clean-up in the event an external spill response

agency is called.

3.5 Blood Spills

A large blood spill that cannot be easily contained & cleaned by staff at the scene should be

designated as a Code Brown. This applies to blood only.

3.6 Area Managers/Supervisors are responsible to ensure


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a) Code brown & spill education is provided to staff on hire with annual review & testing; area staff are trained to respond in an appropriate & safe manner with the necessary spill clean-up equipment including the appropriate PPE to be worn based on the hazard; training for flammable materials is provided every six months; code brown & spill education is recorded & kept for two years.

b) Hazardous materials inventory is completed & Material Safety Data Sheet (MSDS) information is available & current

c) All hazardous materials within their area have specific response procedures, which may include, but not be limited to MSDS

d) Availability of spill clean-up equipment & supplies (if applicable) with regular monitoring & replenishment after use

e) Exposed staff are escorted to receive medical attention and a Safety Occurrence Report is completed for any hazardous spill (Code Brown & non-code Brown) with notification to all applicable areas e.g. HSW, EDM, Waste Management Coordinator etc.

f) Prompt investigation & determination of root cause of spill with corrective/preventive actions implemented;

g) Debriefing meeting occurs within an appropriate period of time & includes all relevant parties h) Include location of area spill kit (if applicable) on HHS Area Specific Code Information Record

located in the area’s Emergency Preparedness Binder.

3.7 Staff are responsible to

take part in annual education, training and exercise/testing related to hazardous material spill management, WHMIS and Code Brown;

locate & know how to use spill clean-up equipment & supplies in their area/unit; know when to call a code brown; complete a Safety Occurrence Report for any hazardous spill exposure participate in completion of the Safety Occurrence Report, investigation & root cause analysis for

the spill event.

3.8 Incident Manager (i.e. HSW, IPAC, Pharmacy or NM Radiation Safety Officer) is responsible to

respond to Code Brown pages 24/7

provide direction & consultation to all stakeholders (i.e. Engineering, CSS etc…)for the overall management of the spill clean-up

determine “all clear” notification

ensure a debriefing meeting is scheduled within an appropriate period of time, facilitate the process & summarize the debriefing meeting in the Safety Occurrence Report.

4.0 Procedure- See HHS Code Brown Summary Checklist on page 1

5.0 Definitions

Spill: Any unplanned or uncontrolled release of any hazardous material (biomedical, cytotoxic,

chemical or radioactive) that can pose a potential safety or health risk to people or the

environment.


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Reportable Spill to the Ministry of Environment (MOE) is a discharge of a pollutant that causes or is

likely to cause an adverse effect and encompasses all of the following circumstances:

into the natural environment from or out of a structure, vehicle or other container that, in quality or quantity, is abnormal in light of all the circumstances of the discharge The Waste Management Coordinator or designate is to be contacted to notify the MOE & City of

Hamilton Spills Center-see Appendix

6.0 Cross References

Biomedical Waste Disposal Protocol

NM- Emergency Radioactive Spill Response, Investigations & Reporting

Cytotoxic Agents: Safe Handling Policy-Segregation, Preparation, Transportation & Waste Disposal

Mercury Spill Procedure

Spill Response Protocol

Workplace Hazardous Material Information System (WHMIS) Procedure

MAC-Occurrence Reporting and Management Protocol

Addendum- JCC Chemo Suite Use of Ventilation Switch in Code Brown

7.0 Developed By, In Consultation With:

CSS Waste Management; Emergency Disaster Management; Infection Prevention & Control; Health,

Safety & Wellness; Joint Health & Safety Committees; Pharmacy

8.0 Approved By EDM Steering Committee


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SPILL CONTROL PROCEDURES

IN CASE OF SPILL

A) DETERMINE THE TYPE OF SPILL, IS IT A MINOR OR A MAJOR SPILL?

Definitions: - Minor spill – A minor spill is small enough that it can be safely cleaned up using the spill kit

- Major Spill – is one that cannot be contained safely with the materials on the site and or

threatens to enter the sewer system or travel beyond the boundaries of the plant to endanger

the environment.

B) IMMEDIATELY ACTIVE A CODE BROWN IF ANY SPILL (MAJOR OR MINOR)

OCCURRED

Call 5555 state: site, location, Code Brown and Spill type i.e. Flammable liquid.

Wait for directions from Incident Manager

C) CONTAIN AND CLEAN UP THE SPILL, BY QUICKLY SHUTTING OFF THE SOURCE IF

POSSIBLE. IF THE SPILL IN MINOR, USE ALL NECESSARY ITEMS LOCATED IN THE

SPILL KIT TO CONTROL, AND CLEAN UP THE SPILL. IF THE SPILL IS MAJOR FOLLOW

THE INSTRUCTIONS PROVIDED BY THE INCIDENT MANAGER.

D) CONTROL ANY IGNITION SOURCES. THE SPILL SHOULD BE ISOLATED FROM ANY

POSSIBLE IGNITION SOURCES SUCH AS SMOKING, WELDING ELECTRICAL

EQUIOPMENT AND GRINDING.

E) INITIATE VENTILATION MEASURES. VENTILATE THE AREA TO PREVENT VAPOURS

FROM SETTLING ON THE FLOOR, IN PITS STAIRWELLS AND TRENCHES OR OTHER

AREAS BELOW THE FLOOR LEVEL

F) IN CASE OF FIRE CALL 5555 FOLLOW THE CODE RED SAFETY PLAN.

G) ARRANGE FOR THE DISPOSAL OF WASTE MATERIAL IN ACCORDANCE WITH THE

MINISTRY OF ENVIRONMENT AND ENERGY REQUIREMENTS.

External Spill Company is Quantum Murray 1-877-378-7745


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All employees involved in the handling, use and storage of flammable and combustible

liquids are required to know the hazard associated with these liquid. The Emergency Spill

Incident Manager shall be responsible for ensuring this data is available to employees and

that Material Safety Data sheet are updated when any new materials is brought into the

facility or a new material is produced.

Personnel should be trained both in prevention and responding to an incident in order to

create a risk awareness among the employees. All personnel should have practical

training in alarm procedures, lifesaving, and the reduction of environmental damages and

on the proper method of handling a minor spill using the emergency spill kit.

Proper protective clothing and equipment outlined in the Material Safety Data Sheets shall

be provided in the spill kit and shall be tailored to the particular facility (i.e. rubber gloves,

rubber boots, self-contained breathing apparatus etc.) This spill kit shall be checked

regularly and inspected after every use.

A preventative maintenance program shall be implemented, including training of new staff

within three months of being hired and for experienced staff every six months.

Mechanical protection will be provided for all vessels carrying flammable or combustible

liquids to prevent spills and leaks.

A COPY OF THIS PLAN SHALL BE POSTED IN ALL AREAS THAT HANDLE, STORE OR

USE FLAMMABLE AND COMBUSTIBLE LIQUIDS.

Appendix – E

Fire Site Plan


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fire safety plan - fhs.mcmaster.ca

Documents