EDITIONEN·FR·ქართ
ASF Logo

Accréditation Sans Frontières

International Accreditation of Healthcare Facilities

Start accreditation  

EMG-SOP-001: Fire Safety and Evacuation

Organisation name
Site or unit
Standard operating procedure
Fire Safety and Evacuation
Document ID EMG-SOP-001-EN Version 1.2
Status To be issued Issue date  
Review date   Replaces 1.0
Owner Clinical lead for this procedure Approved by  
Classification Internal Applies to All clinical areas
Signature  

This is a controlled copy when approved. Printed copies are uncontrolled; check the version against the document register before use.

Contents

1. Purpose 2
2. Scope 2
3. Definitions 2
4. Background 2
5. Responsibilities 3
6. Materials and equipment 3
7. Safety and exceptions 3
8. Procedure 3
9. Worked examples 4
10. Decision points 5
11. Escalation 5
12. Monitoring and compliance 6
13. Records 6
14. Training and competence 6
15. Related documents 6
16. References 6
17. Change history 6
Abbreviations 1
Annex A. Drill and test record 7

Abbreviations

Abbreviation Meaning
EMG-FRM-001 Alarm test record (form)
EMG-FRM-002 Drill record (form)
SOP Standard operating procedure

Key points

  • If you find a fire: raise the alarm at the nearest call point, call the fire number, and protect people nearby.
  • Fight a fire only if it is small, you have the right extinguisher, you can keep a clear exit behind you, and you are not putting yourself at risk.
  • If the alarm sounds: follow the evacuation plan for your area, help people who need help, close doors, and do not use lifts.
  • Keep all exits, corridors and stairs clear. Never store items in escape routes.
  • Record every test and drill on EMG-FRM-001 and EMG-FRM-002.

Purpose

To prevent fire, keep people safe if one starts, and make sure every patient, visitor and member of staff can leave the building quickly and safely. In a health-care building, many patients cannot move without help, so evacuation depends on staff who know the routes and have practised them.

Scope

Element Coverage
Who All staff, students, contractors, patients and visitors at the facility.
Where All buildings, wards, theatres, laboratories, stores, car parks and outdoor areas.
When At all times. Specific duties apply on an alarm, during drills, and during daily checks.
Not covered Chemical or radiation emergencies, which have their own plans.

Definitions

Term Meaning
Escape route Any exit, corridor, stair or passage used to leave the building in an emergency. The route is shown on the evacuation plan for the floor.
Assembly point The designated outdoor area where people gather after evacuation, and where the head count is taken.
Fire warden A trained member of staff who checks an area, takes the lead in evacuating it, and reports to the fire officer.
Horizontal evacuation Moving people to the next fire compartment (a fire-resisting area), where the building is designed for it, before they leave the building.

Background

In a health-care building, fire is most dangerous to patients who cannot move without help, and to staff who are moving them. The measures that protect people are simple: escape routes that are kept clear, a fire that is raised at once, a practised evacuation, and staff who know their role. The facility’s evacuation plan sets the routes and assembly points for each building, and it takes precedence over general advice in this SOP.

Responsibilities

Role Responsibility
Clinical director Approves this SOP and receives the quarterly drill report.
Facilities or fire officer Maintains the alarm, the extinguishers and the evacuation plan; runs the drills; keeps the test records.
Ward or unit manager Keeps the area clear, appoints fire wardens, and records the daily check.
Fire warden Checks the area on an alarm, leads evacuation of their area, and reports to the fire officer.
All staff Follow the evacuation plan, keep exits clear, and report any hazard at once.

Materials and equipment

Item Requirement
Fire alarm and call points Tested as recorded on EMG-FRM-001.
Extinguishers and fire blankets Inspected and in date, and placed where the evacuation plan shows.
Evacuation plan and signage Displayed on each floor, with the escape routes and the assembly point marked.
Evacuation equipment Evacuation sheets or chairs where the plan provides them, with staff trained to use them.

Safety and exceptions

  • Lifts. Do not use lifts in an evacuation, unless they are designated for evacuation and the fire officer directs their use.
  • Your own safety first. Do not put yourself at risk to fight a fire. Leave the area, close the door behind you, and tell the fire officer.
  • Patients who cannot move unaided. Move them following the evacuation plan, with fire wardens, and do not leave them alone. Use horizontal evacuation where the building is designed for it.
  • Smoke. Stay low, keep the door closed behind you, and use the nearest protected route.

Procedure

Before you start

  • Know the nearest exit, the second exit, and the assembly point for your area.
  • Know where the nearest call point and extinguisher are.

Step 1. If you find a fire

  1. Raise the alarm at the nearest call point, so that the building is alerted.
  2. Call the fire number and give the exact location, the type of fire and whether people are at risk.
  3. Protect people nearby. Close the door of the room if it is safe to do so.
  4. Fight the fire only if it is small, you have the right extinguisher, your exit is clear, and you are not at risk. Use the extinguisher from the side of the fire, aiming at the base. If the fire grows, leave.

Step 2. If the alarm sounds

  1. Stop what you are doing. Make the patient or visitor safe, switch off equipment that is safe to switch off, and close the door.
  2. Follow the evacuation plan for your area. Where you are a fire warden, check your area.
  3. Help people who need help. Do not use lifts.
  4. Go to the assembly point, and report to the fire officer. Do not go back into the building until told it is safe.

Step 3. Record tests and drills

  1. Record every alarm test on EMG-FRM-001, and every drill on EMG-FRM-002, with the time taken to evacuate.
  2. Review the record at the monthly meeting, and act on any problem found.

Worked examples

Situation What to do
A waste bin in a ward corridor catches fire. Raise the alarm first. Call the fire number. If the flames are small and you have the extinguisher nearby, with an exit behind you, fight the fire from the side, aiming at the base. If the fire grows, leave, close the door, and go to the assembly point.
The alarm sounds on the second floor. A patient in a bed cannot walk. Follow the evacuation plan for the floor. Call for the fire wardens, and move the patient using the evacuation equipment and the plan. Do not use the lift. Keep the patient with a member of staff at all times, and record who went with them.
A fire door is propped open with a trolley in the escape corridor. Move the trolley, or if you cannot, report it at once to the ward manager and the facilities team. Record the hazard and the action taken.
Fire found, or alarm soundsFire found?YES: raise the alarm at the call point; call the fire numberwith the locationProtect people nearby; fight only if small, with the rightextinguisher, an exit behind you, and no risk to youFire grows, or smoke you cannot control?YES: leave at once, close the door, go to the assembly pointAlarm sounds: follow the evacuation plan for the area; helppeople who need help; do not use liftsAssembly point: report to the fire officer; do not re-enteruntil told it is safe

Figure 1. Fire found or alarm sounds

Decision points

If Then
Small fire you can control safely Raise the alarm first; then use the nearest extinguisher with an exit behind you.
Smoke or fire you cannot control Evacuate at once and call the fire number.
Alarm sounds without a known cause Evacuate at once.
Escape route blocked Use the second route; report the blockage immediately.

Escalation

Event Inform Timescale
Any fire or alarm Fire officer and clinician in charge Immediately
Blocked escape route found Ward or unit manager and facilities Immediately
Failed test or drill Facilities or fire officer and clinical director Within one week

Monitoring and compliance

Indicator Target Method Frequency Owner
Tests and drills recorded on time 100% of scheduled tests and drills Review of EMG-FRM-001 and EMG-FRM-002 Monthly Facilities or fire officer
Escape routes clear at the daily check 100% of checks Daily check record Monthly Ward manager
Evacuation time recorded and reviewed Target set by the fire officer Drill record Quarterly Fire officer

Records

Record Kept in Retention
Alarm test record EMG-FRM-001 Facilities file As set by the institutional retention policy
Drill record EMG-FRM-002 Facilities file As set by the institutional retention policy

Training and competence

  • Induction: the alarm, the fire number, the extinguisher, the assembly point, and the evacuation plan for the area.
  • Annual update: participation in a drill. Fire wardens receive additional training and a practical evacuation exercise each year.

Related documents

ID Title Relationship
EMG-SOP-001-EN Fire Safety and Evacuation This SOP

References

  1. ASF Expert Committee decision on fire safety and evacuation. No external guideline was cited. The facility’s fire risk assessment and evacuation plan take precedence where they differ from this SOP, and must be confirmed by the fire officer.

Change history

Version Date Summary of change Approved by
1.0   First approved version. ASF Expert Committee
1.2   Substantive revision: fire-found and alarm steps, extinguisher rule, evacuation of patients who cannot move, smoke, and worked examples.  

Annex A. Drill and test record

Use this record for each audit session. Record one line per drill task observed. Enter Y, N or NA as shown in the column heading.

Date Area Type (test / drill) Time to evacuate Assembly point reached (Y / N) Problems found Action taken Observer (initials)
Download this SOP as PDF (A4, with figures)
Download this SOP as an editable Word file (text and tables)