Nurse

PICU

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

NICU

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Surgical Services

Code RED

SURGICAL SERVICES:

Perioperative Team Members- The procedure personnel involved directly in the procedure.

  • Perioperative Team members will perform a risk assessment prior to each procedure to include bedside procedures in ICUs
  • The Registered Nurse Circulator on the team will assess the fire risk for the procedure as A, B, C, D, or E or any combination of the letters before the procedure begins. The letter designation is determined and assigned to each of the following critical questions:
    • A Is an alcohol based prep agent or other volatile chemical being used preoperatively?
    • B Is the surgical procedure being performed above the xiphoid process?
    • C Is open oxygen or nitrous oxide being administered?
    • D Is Electrosurgical Unit, laser, or fiber-optic light cord being used?
    • E Are there other possible contributors?
  • Perioperative Team Member will perform interventions for prevention of fire on or in equipment:
    • Inspect electrical cords and plugs for integrity and remove from service if frayed or damaged
    • Check biomedical inspection stickers on equipment for currency, if outdated remove from service until inspected
    • Keep fluid off equipment e.g. electrosurgical unit, laser
    • Do not bypass or disable safety features such as audible alarms on equipment
    • Use medical devices according to manufacturer's recommendations
  • Perioperative Team Members will perform the following interventions for handling a fire on a patient:
    • Small flames or a small area:
      • Communicate fire to team members
      • Pour saline or water on the fire slowly to prevent spreading
      • Place an individual’s arm between the patient’s head and the fire, than lay a wet towel or sponge over the flame and sweep it towards the patient’s feet
      • Lift the material used to smother the flame to vent heat
      • Remove burning material from the patient
      • Asses the surgical field for a secondary fire on the underlying drapes or towels
      • Assess the patient for injuries and report to a physician
      • Activate alarms, if necessary
      • Notify the appropriate chain of command
    • Large flames or a large area:
      • Communicate the presence of the fire to team members
      • Communicate with the anesthesia care provider to stop the flow of breathing gases to the patient
      • Activate alarms, if necessary
      • If drapes are involved, remove the drape to the floor, rolling it on itself to smother the fire
      • Avoid moving the drape into what may need to be the route to evacuate the room
      • Assess the surgical field for a secondary fire on the underlying drapes or towels
      • Assess the patient for injury and report injuries to a physician
      • Verify the flames are extinguished and use a fire extinguisher, if necessary
        • Employ the PASS technique when using a fire extinguisher
          • P = pull
          • A = aim
          • S = squeeze
          • S = sweep
      • Notify the appropriate chain of command
    • Fire in a patient
      • Communicate the presence of fire to all team members
      • Consult with anesthesia care provider to determine the necessary actions to extinguish an airway fire
      • Assist the anesthesia care provider with
        • Disconnecting and removing the breathing circuit
        • Turning off the flow of oxygen
        • Removing the ET tube and any segments of the burned tube that remain in the airway
        • Pouring saline or water into the airway if instructed
        • Re-establishing the airway
        • Examine the airway
      • Assess the surgical field for a secondary fire on the underlying drapes or towels
      • Assess the patient for injury and report injuries to a physician
      • Activate alarms, if necessary
      • Notify the appropriate chain of command
    • Fire on a piece of equipment
      • Communicate the presence of fire to all team members
      • Disconnect equipment from its electrical source if possible
      • Shut off the electricity to the piece of equipment at the electrical panel, if it is not possible to remove the plug from the outlet, by calling 57-5555
      • Shut off gases to equipment, if applicable
      • Assess the size of the fire to determine whether equipment can be removed from the room safely or if the room needs to be evacuated
      • Extinguish the fire using a fire extinguisher, if appropriate
      • Activate alarms, if necessary
      • Notify the appropriate chain of command
    • Perioperative Team members will perform the following interventions for handling a fire in another area of the building
      • All operating and procedure rooms are notified of the presence of a fire in another area of the building by the person in charge
      • No elective cases are started
      • Perioperative team members will prepare to evacuate
    • Perioperative team will perform the following interventions for handling an evacuation of the Operating Rooms and Minor Procedure Rooms when necessary using RACE
      • R = RESCUE
        • Determine the best method to remove the patient from the area, e.g. procedure bed, gurney, carry
        • Determine the safest location to receive the patient
        • Get adequate assistance
        • Remove the patient and staff members from the room containing the fire or smoke
      • A = ALARM
        • Communicate to the entire perioperative suite, especially adjoining rooms
        • Follow the hospital-wide procedure for activating the organizational alarm system
          • Pull closest fire alarm
          • Call: 57-5555
      • C = Contain
        • Close the doors to the involved room
        • Shut off medical gases to the involved room
        • Turn off electricity to the involved room
      • E = EVACUATE/EXTINGUISH
        • When: When a danger is posed to patients in adjoining areas from fire or smoke
        • Where:
          • Transfer the patients to an area that is beyond the first set of smoke barriers
          • Determine the best area in which surgery may be finished safely on the patient
        • How: Transfer patients by carrying, using a gurney or moving the procedure bed with patient remaining on the bed
    • After a procedure fire, Perioperative Team will insure that all materials and devices involved are saved for later investigation into cause of fire and will provide all materials, devices and incident/occurrence report to the quality/risk management personnel

    Code Delta Level 3 may be initiated

Emergency Department

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

4S Med Surg

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

5S Med Surg

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Hematology Oncology

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Outpatient

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Patient Flow Supervisor

Code RED

Response to Fire Alarm:

  • Respond to location of Code Red
  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Specialty Nurses

Code RED

Specialty Nursing Includes But Is Not Limited To: Clinical Nurse Educators, Advanced Practice Nurses, Nursing Advancement, IV Therapy Nurses, Nursing Informatics

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Critical Care Transport

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Respiratory

PICU

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

NICU

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Surgical Services

Code RED

SURGICAL SERVICES:

Perioperative Team Members- The procedure personnel involved directly in the procedure.

  • Perioperative Team members will perform a risk assessment prior to each procedure to include bedside procedures in ICUs
  • The Registered Nurse Circulator on the team will assess the fire risk for the procedure as A, B, C, D, or E or any combination of the letters before the procedure begins. The letter designation is determined and assigned to each of the following critical questions:
    • A Is an alcohol based prep agent or other volatile chemical being used preoperatively?
    • B Is the surgical procedure being performed above the xiphoid process?
    • C Is open oxygen or nitrous oxide being administered?
    • D Is Electrosurgical Unit, laser, or fiber-optic light cord being used?
    • E Are there other possible contributors?
  • Perioperative Team Member will perform interventions for prevention of fire on or in equipment:
    • Inspect electrical cords and plugs for integrity and remove from service if frayed or damaged
    • Check biomedical inspection stickers on equipment for currency, if outdated remove from service until inspected
    • Keep fluid off equipment e.g. electrosurgical unit, laser
    • Do not bypass or disable safety features such as audible alarms on equipment
    • Use medical devices according to manufacturer's recommendations
  • Perioperative Team Members will perform the following interventions for handling a fire on a patient:
    • Small flames or a small area:
      • Communicate fire to team members
      • Pour saline or water on the fire slowly to prevent spreading
      • Place an individual’s arm between the patient’s head and the fire, than lay a wet towel or sponge over the flame and sweep it towards the patient’s feet
      • Lift the material used to smother the flame to vent heat
      • Remove burning material from the patient
      • Asses the surgical field for a secondary fire on the underlying drapes or towels
      • Assess the patient for injuries and report to a physician
      • Activate alarms, if necessary
      • Notify the appropriate chain of command
    • Large flames or a large area:
      • Communicate the presence of the fire to team members
      • Communicate with the anesthesia care provider to stop the flow of breathing gases to the patient
      • Activate alarms, if necessary
      • If drapes are involved, remove the drape to the floor, rolling it on itself to smother the fire
      • Avoid moving the drape into what may need to be the route to evacuate the room
      • Assess the surgical field for a secondary fire on the underlying drapes or towels
      • Assess the patient for injury and report injuries to a physician
      • Verify the flames are extinguished and use a fire extinguisher, if necessary
        • Employ the PASS technique when using a fire extinguisher
          • P = pull
          • A = aim
          • S = squeeze
          • S = sweep
      • Notify the appropriate chain of command
    • Fire in a patient
      • Communicate the presence of fire to all team members
      • Consult with anesthesia care provider to determine the necessary actions to extinguish an airway fire
      • Assist the anesthesia care provider with
        • Disconnecting and removing the breathing circuit
        • Turning off the flow of oxygen
        • Removing the ET tube and any segments of the burned tube that remain in the airway
        • Pouring saline or water into the airway if instructed
        • Re-establishing the airway
        • Examine the airway
      • Assess the surgical field for a secondary fire on the underlying drapes or towels
      • Assess the patient for injury and report injuries to a physician
      • Activate alarms, if necessary
      • Notify the appropriate chain of command
    • Fire on a piece of equipment
      • Communicate the presence of fire to all team members
      • Disconnect equipment from its electrical source if possible
      • Shut off the electricity to the piece of equipment at the electrical panel, if it is not possible to remove the plug from the outlet, by calling 57-5555
      • Shut off gases to equipment, if applicable
      • Assess the size of the fire to determine whether equipment can be removed from the room safely or if the room needs to be evacuated
      • Extinguish the fire using a fire extinguisher, if appropriate
      • Activate alarms, if necessary
      • Notify the appropriate chain of command
    • Perioperative Team members will perform the following interventions for handling a fire in another area of the building
      • All operating and procedure rooms are notified of the presence of a fire in another area of the building by the person in charge
      • No elective cases are started
      • Perioperative team members will prepare to evacuate
    • Perioperative team will perform the following interventions for handling an evacuation of the Operating Rooms and Minor Procedure Rooms when necessary using RACE
      • R = RESCUE
        • Determine the best method to remove the patient from the area, e.g. procedure bed, gurney, carry
        • Determine the safest location to receive the patient
        • Get adequate assistance
        • Remove the patient and staff members from the room containing the fire or smoke
      • A = ALARM
        • Communicate to the entire perioperative suite, especially adjoining rooms
        • Follow the hospital-wide procedure for activating the organizational alarm system
          • Pull closest fire alarm
          • Call: 57-5555
      • C = Contain
        • Close the doors to the involved room
        • Shut off medical gases to the involved room
        • Turn off electricity to the involved room
      • E = EVACUATE/EXTINGUISH
        • When: When a danger is posed to patients in adjoining areas from fire or smoke
        • Where:
          • Transfer the patients to an area that is beyond the first set of smoke barriers
          • Determine the best area in which surgery may be finished safely on the patient
        • How: Transfer patients by carrying, using a gurney or moving the procedure bed with patient remaining on the bed
    • After a procedure fire, Perioperative Team will insure that all materials and devices involved are saved for later investigation into cause of fire and will provide all materials, devices and incident/occurrence report to the quality/risk management personnel

    Code Delta Level 3 may be initiated

Emergency Department

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus including Rockland I & II call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

4S Med Surg

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

5S Med Surg

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Hematology Oncology

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Outpatient

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Critical Care Transport

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Physician

PICU

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

NICU

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Emergency Department

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

General Pediatrics

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Hospitalists

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Surgical Services

Code RED

SURGICAL SERVICES:

Perioperative Team Members- The procedure personnel involved directly in the procedure.

  • Perioperative Team members will perform a risk assessment prior to each procedure to include bedside procedures in ICUs
  • The Registered Nurse Circulator on the team will assess the fire risk for the procedure as A, B, C, D, or E or any combination of the letters before the procedure begins. The letter designation is determined and assigned to each of the following critical questions:
    • A Is an alcohol based prep agent or other volatile chemical being used preoperatively?
    • B Is the surgical procedure being performed above the xiphoid process?
    • C Is open oxygen or nitrous oxide being administered?
    • D Is Electrosurgical Unit, laser, or fiber-optic light cord being used?
    • E Are there other possible contributors?
  • Perioperative Team Member will perform interventions for prevention of fire on or in equipment:
    • Inspect electrical cords and plugs for integrity and remove from service if frayed or damaged
    • Check biomedical inspection stickers on equipment for currency, if outdated remove from service until inspected
    • Keep fluid off equipment e.g. electrosurgical unit, laser
    • Do not bypass or disable safety features such as audible alarms on equipment
    • Use medical devices according to manufacturer's recommendations
  • Perioperative Team Members will perform the following interventions for handling a fire on a patient:
    • Small flames or a small area:
      • Communicate fire to team members
      • Pour saline or water on the fire slowly to prevent spreading
      • Place an individual’s arm between the patient’s head and the fire, than lay a wet towel or sponge over the flame and sweep it towards the patient’s feet
      • Lift the material used to smother the flame to vent heat
      • Remove burning material from the patient
      • Asses the surgical field for a secondary fire on the underlying drapes or towels
      • Assess the patient for injuries and report to a physician
      • Activate alarms, if necessary
      • Notify the appropriate chain of command
    • Large flames or a large area:
      • Communicate the presence of the fire to team members
      • Communicate with the anesthesia care provider to stop the flow of breathing gases to the patient
      • Activate alarms, if necessary
      • If drapes are involved, remove the drape to the floor, rolling it on itself to smother the fire
      • Avoid moving the drape into what may need to be the route to evacuate the room
      • Assess the surgical field for a secondary fire on the underlying drapes or towels
      • Assess the patient for injury and report injuries to a physician
      • Verify the flames are extinguished and use a fire extinguisher, if necessary
        • Employ the PASS technique when using a fire extinguisher
          • P = pull
          • A = aim
          • S = squeeze
          • S = sweep
      • Notify the appropriate chain of command
    • Fire in a patient
      • Communicate the presence of fire to all team members
      • Consult with anesthesia care provider to determine the necessary actions to extinguish an airway fire
      • Assist the anesthesia care provider with
        • Disconnecting and removing the breathing circuit
        • Turning off the flow of oxygen
        • Removing the ET tube and any segments of the burned tube that remain in the airway
        • Pouring saline or water into the airway if instructed
        • Re-establishing the airway
        • Examine the airway
      • Assess the surgical field for a secondary fire on the underlying drapes or towels
      • Assess the patient for injury and report injuries to a physician
      • Activate alarms, if necessary
      • Notify the appropriate chain of command
    • Fire on a piece of equipment
      • Communicate the presence of fire to all team members
      • Disconnect equipment from its electrical source if possible
      • Shut off the electricity to the piece of equipment at the electrical panel, if it is not possible to remove the plug from the outlet, by calling 57-5555
      • Shut off gases to equipment, if applicable
      • Assess the size of the fire to determine whether equipment can be removed from the room safely or if the room needs to be evacuated
      • Extinguish the fire using a fire extinguisher, if appropriate
      • Activate alarms, if necessary
      • Notify the appropriate chain of command
    • Perioperative Team members will perform the following interventions for handling a fire in another area of the building
      • All operating and procedure rooms are notified of the presence of a fire in another area of the building by the person in charge
      • No elective cases are started
      • Perioperative team members will prepare to evacuate
    • Perioperative team will perform the following interventions for handling an evacuation of the Operating Rooms and Minor Procedure Rooms when necessary using RACE
      • R = RESCUE
        • Determine the best method to remove the patient from the area, e.g. procedure bed, gurney, carry
        • Determine the safest location to receive the patient
        • Get adequate assistance
        • Remove the patient and staff members from the room containing the fire or smoke
      • A = ALARM
        • Communicate to the entire perioperative suite, especially adjoining rooms
        • Follow the hospital-wide procedure for activating the organizational alarm system
          • Pull closest fire alarm
          • Call: 57-5555
      • C = Contain
        • Close the doors to the involved room
        • Shut off medical gases to the involved room
        • Turn off electricity to the involved room
      • E = EVACUATE/EXTINGUISH
        • When: When a danger is posed to patients in adjoining areas from fire or smoke
        • Where:
          • Transfer the patients to an area that is beyond the first set of smoke barriers
          • Determine the best area in which surgery may be finished safely on the patient
        • How: Transfer patients by carrying, using a gurney or moving the procedure bed with patient remaining on the bed
    • After a procedure fire, Perioperative Team will insure that all materials and devices involved are saved for later investigation into cause of fire and will provide all materials, devices and incident/occurrence report to the quality/risk management personnel

    Code Delta Level 3 may be initiated

Anesthesiology

Code RED

SURGICAL SERVICES:

Perioperative Team Members- The procedure personnel involved directly in the procedure.

  • Perioperative Team members will perform a risk assessment prior to each procedure to include bedside procedures in ICUs
  • The Registered Nurse Circulator on the team will assess the fire risk for the procedure as A, B, C, D, or E or any combination of the letters before the procedure begins. The letter designation is determined and assigned to each of the following critical questions:
    • A Is an alcohol based prep agent or other volatile chemical being used preoperatively?
    • B Is the surgical procedure being performed above the xiphoid process?
    • C Is open oxygen or nitrous oxide being administered?
    • D Is Electrosurgical Unit, laser, or fiber-optic light cord being used?
    • E Are there other possible contributors?
  • Perioperative Team Member will perform interventions for prevention of fire on or in equipment:
    • Inspect electrical cords and plugs for integrity and remove from service if frayed or damaged
    • Check biomedical inspection stickers on equipment for currency, if outdated remove from service until inspected
    • Keep fluid off equipment e.g. electrosurgical unit, laser
    • Do not bypass or disable safety features such as audible alarms on equipment
    • Use medical devices according to manufacturer's recommendations
  • Perioperative Team Members will perform the following interventions for handling a fire on a patient:
    • Small flames or a small area:
      • Communicate fire to team members
      • Pour saline or water on the fire slowly to prevent spreading
      • Place an individual’s arm between the patient’s head and the fire, than lay a wet towel or sponge over the flame and sweep it towards the patient’s feet
      • Lift the material used to smother the flame to vent heat
      • Remove burning material from the patient
      • Asses the surgical field for a secondary fire on the underlying drapes or towels
      • Assess the patient for injuries and report to a physician
      • Activate alarms, if necessary
      • Notify the appropriate chain of command
    • Large flames or a large area:
      • Communicate the presence of the fire to team members
      • Communicate with the anesthesia care provider to stop the flow of breathing gases to the patient
      • Activate alarms, if necessary
      • If drapes are involved, remove the drape to the floor, rolling it on itself to smother the fire
      • Avoid moving the drape into what may need to be the route to evacuate the room
      • Assess the surgical field for a secondary fire on the underlying drapes or towels
      • Assess the patient for injury and report injuries to a physician
      • Verify the flames are extinguished and use a fire extinguisher, if necessary
        • Employ the PASS technique when using a fire extinguisher
          • P = pull
          • A = aim
          • S = squeeze
          • S = sweep
      • Notify the appropriate chain of command
    • Fire in a patient
      • Communicate the presence of fire to all team members
      • Consult with anesthesia care provider to determine the necessary actions to extinguish an airway fire
      • Assist the anesthesia care provider with
        • Disconnecting and removing the breathing circuit
        • Turning off the flow of oxygen
        • Removing the ET tube and any segments of the burned tube that remain in the airway
        • Pouring saline or water into the airway if instructed
        • Re-establishing the airway
        • Examine the airway
      • Assess the surgical field for a secondary fire on the underlying drapes or towels
      • Assess the patient for injury and report injuries to a physician
      • Activate alarms, if necessary
      • Notify the appropriate chain of command
    • Fire on a piece of equipment
      • Communicate the presence of fire to all team members
      • Disconnect equipment from its electrical source if possible
      • Shut off the electricity to the piece of equipment at the electrical panel, if it is not possible to remove the plug from the outlet, by calling 57-5555
      • Shut off gases to equipment, if applicable
      • Assess the size of the fire to determine whether equipment can be removed from the room safely or if the room needs to be evacuated
      • Extinguish the fire using a fire extinguisher, if appropriate
      • Activate alarms, if necessary
      • Notify the appropriate chain of command
    • Perioperative Team members will perform the following interventions for handling a fire in another area of the building
      • All operating and procedure rooms are notified of the presence of a fire in another area of the building by the person in charge
      • No elective cases are started
      • Perioperative team members will prepare to evacuate
    • Perioperative team will perform the following interventions for handling an evacuation of the Operating Rooms and Minor Procedure Rooms when necessary using RACE
      • R = RESCUE
        • Determine the best method to remove the patient from the area, e.g. procedure bed, gurney, carry
        • Determine the safest location to receive the patient
        • Get adequate assistance
        • Remove the patient and staff members from the room containing the fire or smoke
      • A = ALARM
        • Communicate to the entire perioperative suite, especially adjoining rooms
        • Follow the hospital-wide procedure for activating the organizational alarm system
          • Pull closest fire alarm
          • Call: 57-5555
      • C = Contain
        • Close the doors to the involved room
        • Shut off medical gases to the involved room
        • Turn off electricity to the involved room
      • E = EVACUATE/EXTINGUISH
        • When: When a danger is posed to patients in adjoining areas from fire or smoke
        • Where:
          • Transfer the patients to an area that is beyond the first set of smoke barriers
          • Determine the best area in which surgery may be finished safely on the patient
        • How: Transfer patients by carrying, using a gurney or moving the procedure bed with patient remaining on the bed
    • After a procedure fire, Perioperative Team will insure that all materials and devices involved are saved for later investigation into cause of fire and will provide all materials, devices and incident/occurrence report to the quality/risk management personnel

    Code Delta Level 3 may be initiated

Hematology Oncology

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

All Other Physicians

Code RED

All Other Physicians Including But Not Limited To: Orthopedics, Diagnostic Referral, Pathology, Primary Care, Developmental Medicine, Genetics, Immunology, Behavioral Health, Endocrinology, Hematology/Oncology, Neurology, Nephrology, Pulmonology, Rheumatology, Weight Management, Rehabilitation, Otolaryngology, Transition Team, Dentistry, Ophthalmology, Urology

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

The Logistics Center

Emergency Logistic Technician

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Security Command Center Dispatch

Code RED

  • Security Command will announce the Code RED overhead via the Fire Alarm system immediately. "Attention Please …Code Red (Location: Floor/ Department/ Area with the department)".
  • Announce the same information over the “Nemours All” Radio channel
  • The Fire Department is always dispatched upon receipt of a transmitted alarm and the fire department must always respond to the scene to validate the alarm signal when so advised

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Department

Code Delta Level 3 may be initiated

Security

Security Supervisor

Code RED

  • Security Command will announce the Code RED overhead via the Fire Alarm System immediately. Confirmation is relayed to Security by Radio using the Nemours All channel.
  • The Fire Department is always dispatched upon receipt of a transmitted alarm and the fire department must always respond to the scene to validate the alarm signal when so advised
  • Security will respond to all fire alarms on NCH

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Department

Code Delta Level 3 may be initiated

Administration

Incident Command Executives

The Administrator On Call or Incident Command Executive will be notified of any active Code RED on NCH campus.

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

All Other Associates

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Pharmacy

Pharmacy

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Clerk

Clerk/Aides

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Social Work

Social Worker

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Pastoral Care

Pastoral Care

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Rehab and Therapy Services

Rehab and Therapy Services

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Facilities

Facilities Engineering

Code RED

Be available for support in relation to building management systems

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Coordinator or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Clinical Lab

Clinical Lab

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Blood Bank

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Information Systems

Information Systems

Code RED

Data centers have HALON extinguishers available in the event of electrical fires

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Nutrition Services

Nutrition Services

Code RED

Kitchen has available a wet agent extinguisher in the event of a grease fire.

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Radiology

X-Ray

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

MRI

Code RED

DO NOT BRING OUTSIDE FIRE EXTINGUISHERS INTO THE MRI SCANNER ROOM UNLESS THE MACHINE HAS COMPLETED THE EMERGENCY STOP. Non-magnetic extinguishers are available in the MRI suite.

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

CT

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Interventional

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Ultrasound

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Health Information Management

Health Information Management

Code RED

  • Data centers have HALON extinguishers available in the event of electrical fires

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Human Resource

Human Resources

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Environmental Services

Environmental Services

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Materials Management

Materials Management

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Volunteer Services

Volunteer Services

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Critical Care Transport

Critical Care Transport

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Child Life

Child Life

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

Marketing and Public Relations

Marketing and Public Relations

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated

All Other Associates

All Other Associates

Code RED

Staff Response to Fire Alarm:

  • Practice R-A-C-E
    • R - Rescue persons in immediate danger
    • A - Alarm/Alert by pulling the closest fire alarm and call Command Center by dialing 57-5555. If your site is located on the NCH campus call 57-5555. If your site is located off the NCH campus, then call 911 or your building's fire emergency number.
    • C - Contain fire by closing door.
    • E - Extinguish fire (attempt) with closest fire extinguisher or evacuate area. Do not put yourself at risk.
  • Practice P-A-S-S
    • P - Pull the safety pin
    • A - Aim at the base of the fire
    • S - Squeeze the handle
    • S - Sweep from side to side until fire is out or extinguisher is empty
  • Security will respond to all fire alarms on NCH Campus
  • Take count of patients and visitors in your area. (Print or obtain census)
  • Check rooms for patients or visitors (Including bathrooms) and close door once room has been assessed.
  • Check door before opening it. Do not open a hot door.
  • In the event of a fire that cannot be contained without causing harm:
    • Immediately begin moving patients, visitors and staff beyond closed smoke/fire doors. Unless otherwise directed, move patients that are in the area of fire, away from fire through two (2) sets of smoke doors on the same floor.
    • Supply oxygen masks via portable tanks to those in need.
    • Move portable oxygen tanks (cylinders) away from fire area.
    • Patient Flow Supervisor or Fire Department may direct that the zone emergency medical gas control valves can be shut off.
      • Special exception for Preoperative Services or any other anesthetizing locations: A registered nurse under the direction of the anesthesia provider, surgeon/proceduralist or charge nurse may authorize shutting off medical gas supply valves
    • Await further instructions

Horizontal or Vertical Evacuation may be ordered. Begin evacuation of all patients only under the direction of the Fire Marshall

Code Delta Level 3 may be initiated