Hospital Lateral Evacuations

Discussion created by alan.gustin on Jun 28, 2016

We are currently under construction in three different areas of our critical access hospital.  A renovation is taking place in our Respiratory wing; our Main entry is closed as part of a reconfiguration related to the addition of a surgical wing; a final phase of construction is ongoing in our imaging department.  All that to say, there's a lot going on at the moment.


The construction of the new surgical wing required the installation of a new Fire Alarm system.  Up until now, we have had a FA zone annunciation panel in two locations:

  1. Emergency Department nurse station
  2. Acute care Fire Alarm closet

The new surgical wing FA panel is being tied into the old, existing, analog system and the contractor has removed the annunciator panel from the E.D. nurse station, claiming that it doesn't function with the new system.  However, our policy and procedure states that E.D. personnel will read the panel, identify which zone is in alarm, then announce the code red and location overhead, and call the FD.  With the annunciator panel gone, E.D. staff can no longer perform this function.


The local FD is now telling us that we just need to evacuate the entire facility when the fire alarm is activated, and when they show up, they will read the new panel located in the main entrance area - an area that will NOT be staffed 24/7.  This area is currently under construction, and hospital staff has no access to it.  There is a new annunciator panel mounted temporarily outside that the FD has access to, but it is behind a locked construction fence.


Our existing system has a voice dialer to call the local PD, which then notifies the FD.  But we have also been reading the FA annunciator to identify the alarming zone so staff can be alerted to the location of the fire.  This has allowed us to make decisions about who we need to to evacuate, and where they can be evacuated to.


Our concern is this:

Our staff will no longer be able to quickly identify which zone is in alarm in order to make proper code red announcements. We cannot evacuate the entire hospital every time there is a fire alarm.  OSHA regs say we can perform a "lateral evacuation" once the location of the fire is determined. But since CMS has announced the adoption of NFPA LSC 2012 this July, I need to make sure we are in compliance with our Life Safety procedures.


The obvious answer is to have a new fire alarm panel installed in the E.D.  But I could use some advice on what we should do as best practice, and to be in compliance with the 2012 LSC.


Can someone point me to the section of the NFPA LSC 2012 that covers this topic for Critical Access Hospitals?



Alan Gustin

Plant Services Manager
Wickenburg Community Hospital