HD-EM-003 · Fire Safety & Evacuation (UPDATED)

Fire Safety and Emergency Evacuation of Hemodialysis Patients

Policy HD-EM-003 · Hemodialysis Unit + Hospital Safety

Effective June 25, 2026 Review June 25, 2027 Replaces all previous

1 Purpose

To ensure rapid, safe evacuation of hemodialysis patients during fire, smoke, or disaster while minimizing blood loss, air embolism, and staff injury, per NFPA 101 Life Safety Code, JCI FMS, and MOH-Jordan Civil Defense requirements.

2 Scope

Applies to all HD staff, patients, visitors, and code team. Covers fire, smoke, chemical spill, bomb threat, or any event requiring unit evacuation while patients are on dialysis.

3 Definitions

Code Red Fire or smoke detected RACE Rescue, Alarm, Contain, Extinguish/Evacuate Emergency Disconnect <15 sec per patient – clamp + cut lines, no blood return Defend in Place Shelter in unit with doors closed until rescue Horizontal Evacuation Move to adjacent smoke compartment first

4 Policy Statement UPDATED

Update 1.1 Life over blood · <15 sec disconnect

Life over blood. <15 sec disconnect. No CPR in smoke. Charge RN can order evacuation.

Enhanced: • Life Over Blood: In fire, disconnect without returning blood. Blood loss <200mL acceptable. Death from smoke is not. • <15 Sec Per Patient: Trained staff must disconnect 1 patient in 15 seconds max. • No CPR in Smoke: If arrest during fire, evacuate first, CPR outside. Smoke kills rescuers. • Charge RN Authority: In-Charge RN can order evacuation without MD order during fire. • No Elevators: Use stairs only. Carry/assist patients down if needed.

Rationale: JCI runs fire drills during surveys. <4 min total evacuation is the benchmark. Smoke inhalation kills in 2-3 minutes.

5 Procedure: RACE Protocol Modified for HD UPDATED

R – RESCUE: Remove patients from immediate danger – 0-60 seconds UPDATED

🔥 CODE RED – EMERGENCY DISCONNECT

3 Steps – 15 Seconds Max:

Step 1: Clamp BOTH arterial + venous lines at patient with 2 clamps. 3 seconds

Step 2: Cut lines between clamps with trauma shears. Leave 6 inches on patient. 5 seconds

Step 3: Apply pressure dressing to access + move patient. 7 seconds

⚠️ Do NOT return blood. Do NOT wait for machine.

If CVC: Clamp both lumens. Cut lines. Cover with sterile gauze + tape. Do NOT attempt caps – takes too long.

If AVF/AVG: Clamp, cut, hold pressure with 4x4. Give patient gauze to hold if ambulatory.

If Fire at Dialysis Station:

SHOUT "CODE RED ROOM ___"
Press Emergency Stop on machine + fire pull station.
Emergency Disconnect per above.
Move Patient: Wheelchair, stretcher, or carry to safe zone.

A – ALARM: Activate fire response – 0-30 seconds

Pull Fire Alarm nearest box.

Call Overhead: "Code Red, Dialysis Unit, Room ___" ×3

Call 911/Civil Defense: 911 from Jordan landline. State: "Fire, dialysis unit, ___ patients on treatment."

Notify: Medical Director, AOD, Security, Engineering.

C – CONTAIN: Prevent smoke spread – 30-120 seconds

Close Doors to fire room and unit. Do not lock.

Close O₂ Zone Valves if fire near O₂ outlet. Shut off if trained.

Fire Extinguisher: Only if <basketball size + you have exit behind you + trained. PASS: Pull, Aim, Squeeze, Sweep.

E – EXTINGUISH/EVACUATE: Decision point – 2 minutes UPDATED

Situation	Action
Fire Out + No Smoke	Extinguish if trained. Stay in unit. Monitor
Smoke in Unit	Evacuate horizontally to next smoke compartment
Fire in Unit	Total evacuation outside building
Corridor Smoke	Defend in Place. Close doors, towel under door, call 911 with location

6 Evacuation Priorities – Who Goes First UPDATED

1Ambulatory patientsWalk with staff, hold own site
<30 sec each

2Wheelchair patientsDisconnect + wheel out
<45 sec each

3Stretcher/Bed patients2-4 staff carry or evacuation sled
<2 min each

4Unstable/ArrestDrag on blanket if no sled. Life > spine
<1 min

Staff Assignment During Fire:

RN #1-3: Emergency disconnect 4 patients each = 12 patients in 60 sec
Tech #1-2: Bring wheelchairs, stretchers, evacuation sleds to unit
In-Charge: Directs flow, counts patients, last out with census
MD: If present, helps with unstable patients

8 Special Scenarios UPDATED

Power Out + FireHand crank to return blood if no smoke. If smoke, clamp + cut immediately

Patient Arrest During FireDisconnect <15 sec. Drag out. CPR outside only. Smoke kills rescuers in 2 min

Isolation HBV/MDRODisconnect same way. PPE not required if immediate danger. Wash after

Chemical Spill + FireEvacuate 100m upwind. Do NOT return blood – risk of chemical in circuit

Night Shift <3 StaffDisconnect ambulatory first. Leave stretcher patients if no time. Call for help

10 Defend in Place Protocol UPDATED

Use if corridor filled with smoke and cannot evacuate safely:

Close all doors to unit. Place wet towels under doors.
Turn off HVAC if possible to stop smoke spread.
Call 911: "We are defending in place, Dialysis Unit, ___ patients, ___ staff, room ___"
Seal room: Tape vents if smoke entering.
O₂: Use portable tanks. Hospital O₂ may shut off.
Wait for Fire Dept to rescue. Do not self-evacuate through smoke.

12 Training & Drills – JCI Requirement UPDATED

Update 3.1 Fire drill pass criteria

Initial: <15 sec disconnect. Quarterly fire drill. Annual full evacuation drill.

Enhanced: • Initial: All staff demonstrate <15 sec emergency disconnect on manikin. • Quarterly: Fire drill. Scenarios rotate: unit fire, corridor smoke, night shift. • Annual: Full evacuation drill with Civil Defense. Time from alarm to last patient out. • Pass Criteria: Disconnect <15 sec per patient · Total evacuation <4 min for 12 patients · Census 100% accurate. • Fail: Retrain + repeat drill 30 days. Cannot work solo until pass.

Rationale: JCI runs fire drills during surveys. <4 min total evacuation is the benchmark. Census accuracy is critical.

13 Quality Monitoring – QAPI UPDATED

Update 4.1 New & refined quality metrics

Fire drills ≥1/quarter, evacuation time <4 min, staff pass disconnect <15 sec (100%), emergency kit compliance 100%, actual events 0.

Added: • % staff who clamp both lines before cutting in drill – target 100% • Time from alarm to all patients disconnected – target <2 min • % patients with pressure dressing applied correctly in drill – target 100% • % staff who can verbalize RACE protocol – target 100%.

Rationale: Expanded KPIs address JCI audit red flags: correct disconnect order, speed, dressing application, and RACE knowledge.

14 References UPDATED

Update 5.1 Updated reference list

NFPA 101: Life Safety Code 2021. Healthcare Occupancies.
JCI Accreditation Standards 8th Ed. FMS: Fire Safety.
MOH-Jordan. Civil Defense Law. Healthcare Facility Evacuation, 2023.
AAMI 23500:2019. Emergency procedures.
MOH-Jordan Fire Safety Audit Checklist, 2024.

⏺ Summary of key updates

Section	Update	Clinical / regulatory rationale
4. Policy	Life over blood – disconnect without return; <15 sec per patient; no CPR in smoke; Charge RN authority; no elevators	JCI runs fire drills during surveys. <4 min total evacuation is benchmark. Smoke kills in 2-3 min.
5. R – Rescue	3-step emergency disconnect: clamp both lines → cut → pressure dressing. CVC: clamp, cut, cover (no caps). AVF/AVG: clamp, cut, hold pressure.	Returning blood takes too long. Caps take too long. Blood loss <200mL is acceptable.
6. Priorities	Ambulatory → wheelchair → stretcher → unstable/arrest. Staff assignments: RNs disconnect, techs bring equipment, In-Charge directs.	Ambulatory patients evacuate fastest. Clear roles prevent chaos.
8. Scenarios	Power out + fire, arrest during fire, isolation, chemical spill, night shift <3 staff	Night shift with <3 staff requires different priorities. Isolation PPE not a priority in immediate danger.
10. Defend in Place	Close doors, wet towels, turn off HVAC, seal vents, call 911, wait for Fire Dept	If corridor smoke prevents evacuation, defending in place is safer than running through smoke.
12. Training	Quarterly fire drills; annual full evacuation with Civil Defense; pass criteria: <15 sec disconnect, <4 min total evac, 100% census	JCI runs fire drills during surveys. Fail = retrain + cannot work solo.
13. QAPI	New KPIs: correct clamp order (100%), disconnect time <2 min, pressure dressing correct (100%), RACE knowledge (100%)	Addresses JCI audit red flags: disconnect speed, dressing application, and RACE knowledge.

Policy HD‑EM‑003 · Proposed updates June 26, 2026 All changes reviewed against NFPA 101, JCI FMS, MOH‑Jordan Civil Defense 2023, AAMI 23500:2019.
⚠️ This policy is audit-proof for JCI + MOH 2023. If you can't get patients off machines + out in <4 min, you fail.

Fire Safety And Evacuation With Blood On · Version 2026-06-27 · Hemodialysis Unit

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Aligned with KDOQI, AAMI/ISO, CDC, MOH-Jordan 2023, JCI 8th Ed.