Practical Manual v) Periodic equipment testingvi) Well rehearsed drills and liaison with fire department.

These measures are essential to prevent and also organize the system to take appropriate action in case of any contingencies. It is difficult to attain all the seprevention absolutely, therefore, pragmatic approach should replace idealism, the organisation may compromise and should chalk out and reheare what is reasonable within economic and operating limitations Though all components of fire safety are so closely integrated that it's difficult to separate them, all fire elements mentioned above playa prevention role at some stage or other. It is also important that a regular periodic inspection of fire fighting appliances, any obstruction to fire-escape route, careless use of oxygen cylinders, flammable liquids and any other fire programme violation. b) Detection The application of automatic early warning fire detection system has helped a great deal in early detection of fire. The fire detectors require a sensing unit which measures the presence and/or changes in the products of fire, which are basically flame, heat, smoke, and gases. The functioning of detectors are based on these senses, and they are activated when the standards are exceeded, and once detector senses an abnormal condition, it must transmit a signal to an annunciator. This signal can activate any predetermined message or alarm on which an appropriate action can be taken by the ear-marked staff. Fire detection system in most of the hospital services, are combination of sensors due to the varied application presented by the medical care environment. Automatic fire detection has following components: i) Sensors ii) Response detectors iii) Manual call buttons iv) Wiring system v) Electronic hooters vi) Local control panel vii) Main control panel The various types of fire sensors are enumerated as: i) Fixed temperature sensors activate when a pre-selected temperature is reached. These sensors are quite in-expensive and have good reliability. They also require very little maintenance.

ii) Rate of rise sensors activate when the temperature accelerates rapidly. The rate of temperature rise to be exceeded is generally in the range of 15F to 20 F per minute. iii) Combination of fixed temperature and rate of rise of temperature: While the temperature rising devices are reliable and maintenance free but they are rather slow to respond to slow burning and smouldering fire. iv) Photocell detection units sense the mashing of light beam by smoke particles or the reflection of smoke particle into the cell. They are reliable but require considerable maintenance compared to heat sensor. They are also slow to respond to hot clean fire.Fire Manual Guidelines v) Flame sensors are not widely used but do provide fast response to the quick developing fire. They are fairly expensive and require a fair amount of maintenance activity. vi) Products of combustion sensors are quick to respond and to detect either visible or invisible gases. They provide a means for early warning and are used quite extensively despite a relatively high degree 'of false alarms. c) Containment The third element of the fire safety programme is that of containing smoke and fire. The objective is to contain the fire in the area of origin, when this is not possible the concept is one of providing successive level of defence or areas of refuge from fire. There are fire of these basic areas defined in the "line safety code", they are also referred to as the unit concept, which are - room, a compartment, a floor, a building and exits, all these units have distinct function in the fire protection system. i) Unit one: The room is the smallest unit and is the first line of defence. The function of unit one is to provide the first barrier against the passage of smoke. ii) Unit two: The compartment is the second level of defence with the intent of providing two areas of refuge on any given horizontal plane of the hospital. If an area-must be evacuated the initial movement will be horizontal as opposed to a vertical movement. The compartment is 'created by smoke and fire resistive partitions.

iii) Unit three: The floor, or floor assembly, is the next level of containment. The function of the floor assembly is to prevent the spread of fire and smoke from one floor to another, either above or below, the floor involved. These assemblies are penetrated by stairways, shafts and chutes, which require spread protection. iv) Unit four: The building is the fourth unit or level of fire protection. It must remain structurally intact for a period of time. v) Unit five: The exit is the final unit in the unit concept of fire protection, The basic requirement is that at least two remote exits be provided on each floor or fire section of the building. This means that two separate means of exit should be visible from any location in corridor. Note: The containment of the fire can also limit the air needed to sustain combustion. A fire will generally rise to seek ventilation. If it cannot continue to rise, the smoke and heat build up will work back downward, looking for a lateral opening. If there is any air in the room that is breathable it will be found closest to the floor. When a fire is contained extreme caution must be taken when entering the area as the opening of the door may provide the exit the fire is seeking. d) Evacuation The fourth and very important component of the hospital fire safety plan is . evacuation of patients, visitors and staff. The employees of hospital are responsible to see that every patient is evacuated to safety. Practical Manual 5) Some of the psychiatric cases will require embroil support during evacuation for their safety. One has to avoid panic amongst such cases. 6) Orthopaedic cases rendered immobile due to disease or plaster will need total assistance in evacuation. 7) Cases under immediate post operative care will need extra attention specially those with ventillatory support. 8) Patients under going operation The decision for evacuation of the patients from the site of fire will have to be taken by doctor/sister present on the spot depending on the extent and severity of fire. This decision should be taken in due course without creating any undue panic.

The doctor/nurse on the spot will have to take charge of situation till arrival of Fire Safety OfficerlMedical Superintendent. Assessment of total number of patients needing assistance in evacuation should be made by doctor/nurse on .the spot and proj ct additional requirements of manpower, wheel chair, stretchers/trolleys to the Medical Superintendent/Hospital AdministrationlFire Officer. Till arrival of additional help mobilize all available manpower in the ward and utilize available wheel chairs, trolleys and stretchers. 4.11 CHECKLIST FOR FIRE PREPAREDNESS To implement the fire fighting programme effectively every hospital must draw and rehearse the fire preparedness and document the checklist: SI. No. Subject Yes No I) Water hydrant located strategically 2) Water hydrant connections are standardisedl compatible with local fire department loose lines 3) Sprinker system provided where indicated 4)Fire Alarm system working effectively 5) Adequate Fire Extinguisher available 6) Following are available and in working condition in each working area: a) Wall Fire Hydrant b) One Soda Acid/Water, CO2 Extinguisher c) One CO2 Extinguisher d) One Water drum D shaped with 9 buckets of water e) Adequate availability of water 7) Presence of any Electric loose connection! defective improper Electronic points (if yes - location) 8) Any combustible/inflammable material near potential fire point (if yes - material and its location) 9) Fire escape routes are free if no location of any obstruction) 10) Fire escape routes door lock keys available

SI.No. Subject Yes No II) Emergency fire lights and directional sign adequate 12) LPG is stored in a cool and non fire area 13) LPG inspected for linkage on receipt 14) Kitchen exhaust working IS) Fire lift connected with generator is working 16) Fire safety regulation training programme imparted to Hospital staff satisfactorily 17) Up-to-date list of training record maintained 18) Periodic/surprise check carried out 19) Record for periodic check maintained 20) Last periodic/surprise check carried Date Time - This checklist will help you in assessment of fire fighting preparedness in your own set-up and take necessary steps for an effective and efficient implementation of fire fighting programme. 4.12 LET US SUM UP In this unit of practical manual, you have learnt about the importance of having a manual for fire fighting in a hospital. You have learnt about the grades of fire elements of fire safety and various types of fire extinguishers. You have also learnt about the fire preparedness, plan and action to be taken in case of tire in a hospital. It is expected that after going through this unit of practical manual, you will be able to analyse the safety needs of your hospital and draw up a safety plan to protect your hospital from fire hazards. 4.13 FURTHER READINGS Manual for fire fighting at AIIMS Hospital by Dr. RK Sharma. Thomas Jefferson, University Fire Manual on Internet (Physics-web master email). Development of Fire Emergency Programmes, American Hospital Association, Chicago-10, Fillinois: Army instructions 2/91, Fire Fighting Equipment, Govt ofIndia, Ministry of Defence, New Delhi,1991.

Fire Manual Guidelines r : -- L-- -53 Practical Manual ./ Evacuation can be whole or partial and it can f~}low vertical or horizontal flow . The total evacuation of patient from a hospital is however a last contingency. The concept of evacuation plan will be to move the patient horizontally to the safe area (compartment) on the same floor and required than only to shift vertically by two or three floors up and down. Wheel chairs and stretchers are useful and often necessary for evacuation, but they may not be available at the time and place of emergency. The blankets and sheets are most important piece of equipment on hand for evacuation purpose, the blanket/sheets can be handled by one person to drag a patient, and where two carriers are available the blanket can be used as impoverished stretcher. A vertical evacuation plan is mandatory for a high rise building, a building with seven or more stories. The exit routes should be well maintained, the elevators need special consideration for fire evacuation. e) Extinguishment The last element of the hospital fire safety programme is extinguishment of the fire itself. The suppression of fire is achieved either manually or by automatic extinguishing system. Know Your Fire Extinguishers Pressurized Water 2 112 Gallons Range: 3035 feet To be used on Class A Fires (Wood, Paper, Trash, Bedding, etc.) Carbon Dioxide (C02) 5-15Ibs. Range: 4-6 feet. To be used on Class B Fires (Flammable Liquids) and on Class C Fires (EIectri cal) Dry Chemical (ABC) 5-10Ibs. Range: 12-20 Feet Can be used on Class A, B or C Fires

. "\' t Halon (ABC) 5-10Ibs. Range 10-15. feet Ca1 be used on Class A, B or C Fires ............ ! .: . 44 How to Use Your Fire Extinguisher Fire Manual Guidelines For proper and effective use of Fire Extinguisher you can remember the word PASS P Pull the pin A Aim low (at the base of the fire) S Squeeze the handle S Sweep from side to side Remember to keep an exit path between you and fire if you choose to use an extinguisher. The stand pipe and hose located in the hospital building are used to provide quick and convenient water streams on upper/lower stories of high rise buildings. This system of water hose is basically installed to be used by fire department or trained Fire Brigade personnel. The automatic extinguishing system comprises automatic water sprinkle system, which also acts as an alarm device. The operation of the sprinkler is generally activated by a holding link, which melts at a given temperature. The sprinkler systems utilized in hospital are almost always of wet system type as opposed to a dry system. Other piped extinguishing methods are steam, water spray, foam, carbon dioxide, dry chemicals and halon agents. Employees Reaction: Proper employee reaction to the fire situation is one of the fundamental factors in saving lives and property. The safety is a race against time, and the action taken and lack of action in few minutes can make the difference between a minor fire threat and a tragic disaster. Since the employees must react instinctively when fire breaks out, detailed instructions are seldom remembered and hence acronyms expressing essential steps are suggested. A) S A V

E E B) R A C E Save patients or person if in immediate danger. Alarm - Sound the alarm. Vent - Close doors and windows to keep fire contained. Evacuate - use evacuation routes and first-aid Extinguish - fire extinguishers equipment. Rescue those in danger. Activate the nearest alarm, dial security, give location. Close doors, contain the smoke and fire. Evacuate and extinguish. It is essential that to execute these steps properly, all staff members irrespective of their jobs and status must receive continuous in-service training. Unless the personnel have been through the actual experience, a very few persons are able to imagine the swiftness with which the fire danger can spread and the panic that can ensue. Hence, larger the staff members have received the training, the better the chances that they will react correctly under extreme stress. 45 .. Practical Manual 4.4 FIRE SAFETY TRAINING Planning for a fire emergency requires cooperation and understanding from every employee in the hospital. Each employee is potentially the one who may discover a fire or be the first to arrive at the scene of an alarm. The degree of personnel ~tumpver and their effective involvement in carrying out fire preventive measures largely depends upon their continuous in-service and new employees training. Robert Palmer, of North Memorial Hospital in Minneapolis, a national recognized authority on Hospital fire safety, has emphasized the importance of following functions: a) Rescuing those in immediate danger b) Properly reporting the fire

c) Confining the fire d) Securing the fire e) Using the proper extinguisher t) Controlling employees, visitors and patients, and g) Mee!ing and guiding fire department personnel to the scene. The Hospital Administration should earmark a staff member responsible for imparting regular in-service and to new employees fire safety training. The methods for training may include: a) Training session, where employees are actually handling fire extinguishers and patients requiring evacuation. b) Posters of fire prevention and safety. c) Organising fire drills. d) Assessing the knowledge of employees by random stopping and questioning them about their role in case of hospital fire, the person who answers the question correctly should be suitably rewarded. e) Audio-visual aids are very effective means of imparting training as it leaves a clear image in mind, which is easy to recollect. 4.5 GENERAL INSTRUCTIONS 1) All the fire escape routes (staircases and corridors) which have been encroached upon or blocked, must be got cleared for providing emergency exit. / (Sister in charge of the wards to ensure that fire escape staircases and corridors are not encroached upon. Fire safety officer to carry out periodic checks of all the fire escape routes and staircases). 2) All the gas pipelines, particularly the oxygen lines and their regulators, must be thoroughly checked periodically and a proper record of its checking be maintained by manifold room in charge. Any problem of leakage of gas should be immediately intimated to manifold room as well as to the Medical Superintendent Officer/Duty Fire Officer and action to be taken to avoid fire hazard. 3) All heating appliances must be used with a plug and socket of proper ampere and use of excessive load from a particular point. Sister in charge ward to -._ ..- -

laundry directly from the boiler room. For general planning 100 litres of water per bed per day is required for laundry purposes. Linen and Laundry Services If hardness of water exceed 3-4 grains, then water softening plant should also be used, otherwise, scaling of elements will be a constant problem. Linen also acquires yellow hue if washed with hard water. 11) Fire Safety Measures Provision of fire extinguishers is a must throughout the laundry. Workers should be aware of the use of fire extinguishers and must be trained for fire fighting. They should be instructed not to smoke inside the laundry. No electrical equipment should be left on after the working hours. 12) Toilet, Locker and Shower Facilities Enough facilities should be provided so that worker should change their clothes before they start to work and before going home after work. Facilities to wash and clean themselves should be provided. Soap, Oil etc. should be made available. 13) Sewing Room The sewing room should be located near the clean linen and pack preparation room so that wrappers, surgical or obstetrical drapers etc. found tom and reparable could be sorted out, stitched and stored there, so enough space should be provided for the sewing function. 14) Laundry Manager's Office This office should be located as centrally as possible so that the manager may properly supervise the entire laundry operation. The walls should include large vision panel to allow for full view of each area. 3.6.4 Equipment Requirements and Maintenance Equipment planning must be done based on single eight hour shift per day. As and when expansion of hospital takes place a second eight hour shift can be started doubling the capacity of laundry without adding any equipment. The following type

of equipments are generally required for the mechanised laundry: The number of equipments required may be estimated considering the linen load i.e. total weight of linen (in kg. or lb.) to be washed. For practical purposes 'the following factors-the number of beds; the proportion of superspeciality and surgical beds; cost incurred; space available; number of laundry shifts per day; and capacity of the equipment etc. should be taken into account. 1) Trolleys (Dry linen trolleys-diff capacity 50 and 100 kg., Wash room trolleysdiff capacity 50 and 100 kg) 2) Sluice Machine-{l5 kg capacity) 3) Boiler(s) (Boilers which generate-steam or hot water are required for laundry) 4) Washing Machine(s)-50-100 kg. 5) Hydro Extractors-50 kg. 6) Drier(s) (Drying Tumblers)-25-50 kg. 7) Calendering Machine-(single roller) 80" x 60" 8) Steam/Bed Press-(47" x 14" x 9") 9) Electric Irons (Hand Press) 10) Sewing Machine 11) Ironing Table (For using hand presses) 12) Weighing Scales 47 Practical Manual 1) 2) 3) 4) \.,,// 5) 6) 7) 8) 9)

10) 11) 12) / 48 4.6 DO'S AND DON'TS FOR ELECTRICAL FIRE PREVENTION Lights and fans should be switched off when not required or rooms are to be locked. Flexible leads to portable appliances should be well-protected to avoid damage to the insulation of wires. Defective heaters and appliances should be removed immediately from service until these are repaired and tested for satisfactory performance. The capacities of connecting leads, wires and switches must match the load requirements of equipment. All heaters, table and pedestal fans etc. should be fitted with proper guards. Proper and secure earth connections to the heating appliance and other electrical equipment must be ensured. In case any excessive heating, burning smell or sparking in wiring or connections is noticed, control switch should be put off immediately. Do not connect portable electrical appliances to the electrical outlet points through bare and loose ends, proper plug tops be used always. Do not use more than one portable electrical appliance to a single outlet point at the same time. Do not use heaters and high rated equipment on light (5 ampere) socket outlets. No multipurpose plug tops should be used for connecting more than one appliance on a socket outlet point. Extension Boards should be normally used, if unavoidable, the extension boards should not have more than a set of 15 ampere 2 Nos. of socket outlets. 13) Do not add or connect any new electrical equipment unless proper wiring and outlet point of matching capacities are provided. 14) Heaters and hot plates must not be left unattended while these are on. 15) Passages and approaches to main switches, distribution boards and riserrooms.

should not be blocked or locked. 16) Do not pile or stock office-records and other stores near socket outlet points or in riser rooms. . 17) Do not block or close the heat dissipation system and arrangements of electrical machines and equipment. 18) Do not use stabilizers or emergency light topes, as racks. 19) Use of heaters must be avoided in entire basement storing spaces particularly stationery, linen and medical stores. 20) Do not keep heaters and heat producing appliances too close to the overhanging curtains, combustible and other flammable items and chemicals. 21) All the electricians to pay extra attention for using proper insulation after repairs. Fire Manual Guidelines 4.7 ACTION TO BE TAKEN IN CASE OF FIRE IN A HOSPITAL 1) Action by employee or worker on the spot i) To verify the extent of fire outbreak. ii) To intimate at once to immediate superior present on duty in that area. iii) Worker in the area will take immediate action to put off the fire. iv) Sister in chargelDoctors on duty/Sr. worker on duty to inform M.S., "'Security Officer-cum-Fire Officer and fire guard located in the Building. ~-'----2) Action to be taken by sister in charge present on the floor, who acts as a Controlling Authority A) If Small Fire 1) . Organise few personnel available to extinguish the fire using fire extinguisher or by improvisation. 2) Get all inflammable material removed e.g., spirit, oxygen cylinders, cotton, bandage, rags and mattresses etc. from the site of fire. 3) Put off main switch if there is an electric short circuit. 4) Organise shifting of patients, specially, lying cases, with help of available staff and attendants of patients to places of safety. 5)- Get the fire escape route opened. 6) Close the oxygen supply from manifold room and change over to portable oxygen cylinder supply. 7) Ambulant patients to be guided to go to other floors by using staircases. '8) Ask Medical Superintendent Officer/Fire Officer for trained manpower.

9) Do not attempt to evacuate the patients (except from immediate danger) unless ordered to do so by Medical Superintendent, Fire Department. 10) While evacuating organise the shifting of non-ambulatory cases first horizontallyand then by lifts/ramps/staircase, patient charts should accompany the patients unless it is impractical given the emergency. B) . In Case of Big Fire I) Raise fire alarm 2) Fire escape routes to be opened by the key kept in the box, fixed near fire escape route. If key is not available the lock can be broken and open. 3) Walking patients will go out horizontally to rescue area and then by using the staircase. . 4) Lying cases will be shifted away from the site of fire to rescue area, then their rescue will be organised by staff immediately available with guidance from Doctors/Sisters/Senior workers present on the spot, and with the extra manpower which will be sent by M.S.lFire Officer. 5) Doctors/Senior Sisters/Seniormost workers present on the spot will assist sister in charge on duty in operations till Fire Officer or any other officer deputed by M.~.lFire Officer. 49 ' Practical Manual / 50 4.8 PROCEDURE AFTER FIRE ALARM Security: Security will meet and direct the City Fire Department to the fire location. They will also maintain communications at the fire and direct those not involved in the emergency to evacuate the area. They are authorised to stop others from entering the building in jeopardy. They will call the fire department and give street address and floor number where the incident is occurring. They will also communicate with Maintenance and Plant Operations to assure that everyone is aware of the alarm. Telephone operators: Immediately upon being notified of a fire or visible smoke, telephone operators will immediately initiate rehearsed fire drill. Operating rooms: If surgery is in progress, all decisions affecting the patient's welfare will be made by the surgeon in charge. Operating room personnel must be familiar with the locations of medical gas shut-offs.

Maintenance control room: Upon receipt of an alarm, Control Room personnel will despatch via mobile radio all maintenance employees assigned to the Emergency Response Team to the fire location. They will also notify security to . assure that everyone has received the alarm. Emergency response team: Employees from the Maintenance, Security and Environmental Health and Safety Departments staff are the Emergency Response Team. They shall immediately upon notification of a fire alarm proceed to the area of alarm. They should pick up fire extinguishers as they approach the area in jeopardy. Elevators: During the period of alarm, elevators will be returned to the ground floor level and remain inoperative. Security will take the Emergency Response Team and Fire Department to the floor below the fire, via elevator if necessary. The emergency Response Team is directed by Hospital Medical Superintendent! Fire Officer, Director of Maintenance and Plant Operations or the senior team member present. 4.9 WHAT TO DO IN CASE OF FIRE IN NON-PATIENT BUILDINGS 1) Pull the nearest fire alarm box. Dial designated telephone, give the location of the fire. 2) Be familiar with fire exits, fire alarm boxes and fire extinguishers in the building where you work or live. 3) When the fire alarm sounds, evacuate your area and go to the nearest fire exit stairway; close doors behind you. In building with a PA (Public Address) system, there will be an announcement of "Fire Alarm, All Clear" following the silencing of the bells. In buildings without a PA, the silencing of the bells will serve as "All Clear". If you have been trained in the use of portable fire extinguishers and 'you decide to fight the fire, always position yourself between the fire and a path of escape. Never try to extinguish a fire until everyone has been evacuated from danger 4) I Note: Fire Manual Guidelines a) While giving information to aforesaid authorities speak clearly without creating "PANIC" to the patients, staff and to the informer.

b) Specify the exact location of the fire indicating its severity. c) While intimating the Local Fire Brigade tell them the route they should adopt for an early and easy excess to fire location. Use of Fire Extinguishers See Section 4.2 (e) of Unit 4 of this block. For Fires Other than Electrical or Oil Fires Water, CO2 fire extinguishers, water in 'D' shape water drums containing 9 buckets, should be used. In case fire is on bigger magnitude, then water hoses connected to wall fire hydrant should be used till arrival of the Delhi Fire Brigade. \ ' 4.10 EVACUATION PLAN IN THE EVENT OF FIRE There are two approaches, which can be implemented for evacuation. Evacuation Types Partial: The severity of the incident dictates the degree of evacuation. Always begin with persons in the most immediate area of danger. Keep the doors of patient rooms closed until they can be' moved to safety. Total: If fire or smoke conditions warrant, a total floor evacuation will be called for. The decision to totally evacuate will be determined by the Medical Superintendent/Chief Executive Officer, the Director of Environmental Health and Safety. : General principles of evacuation in Multistorey Building: 1) Horizontal evacuation is easier than vertical evacuation, 2) Evacuate lying cases horizontally first and than evacuate vertically down. 3) Evacuate patient to three floors down depending on the site of fire as the floor immediately above and below has potential risk of fire if it is not brought under control. 4) Evacuate able bodied and ambulant patients preferably by stairs. 5) Evacuate lying cases by lift if possible. Patient Care Areas Requiring Special Attention There are many problems in evacuation of following type of patients from patient care areas. These are: 1) Disabled patient or lying cases needs support. 2) Life support measuresIike oxygen etc. may be required for patient even during evacuation. Evacuation with ventilatory support.

3) Paediatric cases and babie~' in nursery will need assistance from attendants. 4) Unconscious cases required to be evacuated as lying cases, 51 I.