Purpose:

To establish the minimum standards for hospital responses to fire alarm activations and building evacuation procedures. These standards were approved by a joint effort among the North Carolina Division of Facility Services, Mecklenburg County Code Enforcement Division and the Charlotte Fire Department.

Policy:

I.                    Fire Alarm Activation Sequence:

A.     Upon activation of the building's fire alarm system, the notification devices, including the audible and visual devices as well as the paging announcement, shall operate in the following sequence:

1.      The audible and visual notification devices shall operate for a minimum of 15 seconds throughout the entire facility. Exception: In lieu of audible alarm devices, only the visual devices shall be permitted in critical care areas.

2.      Upon completion of the 15 second period, paging shall commence for the next 45 seconds and shall be repeated a minimum of three 3 times. It is recommended that the announcement or page be made every 15 seconds.

3.      At the end of the 45-second paging period, the announcement or page shall be made every 2 minutes until the fire officer in charge has given approval for alarm reset.

4.      Throughout the entire alarm sequence, the visual notification appliances shall continue to operate until the situation is abated.

II.                 Evacuation Procedures:

A.     Upon activation of the fire alarm system, if it is determined that an evacuation is necessary, the following procedures shall be followed:

1.      Activate the closest manual pull station to alert other building occupants.

2.      Notify the fire department and summon hospital staff to the immediate area.

3.      Evacuate all patients and occupants in the immediate area and relocate them to the closest safe area of refuge.

4.      Clear all hallways and corridors in the affected area(s) close all doors to isolate the fire area.

5.      Manually recall all elevators in the affected area(s) to the ground floor and provide elevator keys to the fire department upon their arrival.

6.      Assist the fire department with providing any additional keys and/or the location of the affected area(s).