1. Environment of Care

2. Fire Prevention – Life Safety

3. Fire Prevention - Life Safety
Fire is a concern for everyone, but it is a special concern in hospitals because patients are often unable to move to safety by themselves.
The following slides are a summary of Joint Commission regulations and IU Health policies on fire prevention and life safety.

4. Requirements
Egress corridors must remain clear and unobstructed at all times to allow immediate evacuation without delay.
The Joint Commission permits in-use items to remain in the corridor (less than 30 minutes). All in-use items must be removed from the corridor in the event of a fire or fire alarm activation.
Code carts, isolation carts, and chemo carts associated with a patient are considered in-use at all times.
Fire alarm pull stations, fire alarm strobes, and fire extinguishers must remain unobstructed at all times.
Fire doors must never be blocked by any item.
Fire doors cannot be propped open by any object.

5. Requirements
No items are permitted to be stored within 18 inches of sprinkler deflectors (24 inch clearance required in non - sprinklered spaces).
Compressed gas cylinders must be stored in accordance with IU Health policy EC prod.iuhealth.org/sites/PoliciesAndProcedu res/Lists/Policies/ePolicy.aspx?ID=1311
A general rule of thumb is no more than 12 full oxygen cylinders (“E” cylinders) in any one smoke compartment.

6. Interim Life Safety Measures (ILSM)
Staff should be aware of Interim Life Safety Measures that may be implemented to compensate for maintenance or construction activities.
Examples of Interim Life Safety Measures include:
Alternative exits or alternate egress paths;
Additional staff training; and/or
Additional fire drills for affected buildings or departments.

7. RACE and PASS
Whenever the fire alarm sounds, staff is expected to be aware of the location of the alarm and implement applicable elements of the department specific fire response plan (including RACE).
To operate a fire extinguisher, follow PASS.
RACE
Rescue anyone in immediate danger.
Activate – pull alarm and call
UH/RI MH
Saxony
IUHPL
44 Morgan
Contain – Close doors
Extinguish if trained/Evacuate as required.
PASS
Pull the pin
Aim at the base of the fire
Squeeze the handle
Sweep from side to side

8. Medical Gas Management
In a fire emergency, medical gases may need to be turned off to control the spread of fire.
The unit charge person or designee is responsible for determining if zone valves must be turned off.

9. Hazardous Materials & Waste

10. Hazardous Materials & Waste
Hazardous materials are found throughout IU Health for a variety of uses. The following guidelines help ensure patient, visitor and staff safety:
Chemical Storage
All containers must be labeled with the following:
Contents
Hazards
Personal protective equipment (PPE) needed when using the product
Any emergency contact information provided by the manufacturer.
All chemicals must be stored below eye level.
Chemicals should be stored in appropriate locations
NOT under sinks
NOT near food
Hazardous Waste
Sharps containers must be secured and cannot be filled past the fill line.
Hazardous Waste containers must be properly labeled
Hazardous Waste must be disposed of in accordance with EC

11. Hazardous Materials Spills
All spills are to be reported to Security Dispatch
UH/RI MH
IUHPL
Saxony
Morgan
Hazardous chemical spills/releases shall be handled in accordance with EC prod.iuhealth.org/sites/PoliciesAndProcedures/Lists/Policies/ePolicy.aspx?ID=1332
Chemotherapeutic/hazardous drugs shall be handled in accordance with EC prod.iuhealth.org/sites/PoliciesAndProcedures/Lists/Policies/ePolicy.aspx?ID=1386

12. Chemo/Hazardous Drug Spill Kits
Steps for handling a small hazardous drug spill (≤ ½ ft2):
Limit access to the area and post sign
Obtain spill kit and don PPE
Soak up liquids and collect dry residue
Put all contaminated materials back into the chemo spill kit
Clean area well x 3 with detergent and water follow with clean water x 3
Remove all PPE and discard in the spill bucket
Seal spill kit and place in BLACK Hazardous Bin or contact pharmacy
Document the event and complete incident report
For further guidance, refer to IU Health policy EC Lists/Policies/ePolicy.aspx?ID=1386
Spill kits are stored on those units with a high use of hazardous medications or can be ordered through the pharmacy in an emergency situation (IUH Morgan must order through Purchasing).

13. Safety Data Sheets
Safety Data Sheets (formerly Material Safety Data Sheets) describe the physical and chemical properties of a hazardous chemical. They contain useful information such as toxicity, flash point, procedures for spills and releases, storage guidelines, and exposure control/personal protection.
Safety Data Sheets (SDS) can be found HERE
After clicking the link, simply type in the:
product name;
and click search
A list of all matching SDS will populate and you can download the pdf version to view or print.
Any new SDS should be sent to Safety & Security, Hazardous Material Coordinator

14. Emergency Eye Wash Stations
Eye wash stations are found throughout IU Health in areas where risk of exposure to caustic or corrosive chemicals are used.
Eye wash stations must be tested weekly and documented using a standardized form. Completed forms should be sent to Safety & Security. CLICK HERE
In the event of an exposure, you must flush the eyes for a minimum of 15 minutes. Hold both eyelids open with thumb and index finger and remove contacts as soon as possible.
Report to Employee Health (during normal business hours) or the Emergency Department (after hours) and complete an employee incident/exposure report as soon as feasible. CLICK HERE
Always keep eye wash stations clear of any obstructions.

15. Wellfield Protected Area
White River Wellfield District
What is a Wellfield?
Several AHC Facilities are located in a protected District where groundwater is resourced for drinking water for Marion County. This District is shown in shades of blue on the adjacent map.
What do I have to do?
Follow existing IU Health Policies such as:
Report spills to Security
Store chemicals appropriately
Dispose of waste properly
Receive this Awareness training yearly
Time of Travel for Groundwater to Drinking Water Well

16. Medical Equipment

17. Medical Equipment
Medical equipment = devices that provide diagnostic and therapeutic treatment to a patient.
Medical equipment may have an inspection sticker, color changes annually.
“Due Date” shows the month Preventive work is to be done
Contact Clinical Engineering at or to report out-of-date equipment.
IUH Morgan contact or to report out-of-date equipment.

18. Medical Equipment
All other medical equipment will have a grey “Approved For Use” sticker to show that no routine maintenance is performed.
There are 2 different styles of stickers that mean the same thing.
These devices are inspected when new, after a repair, or when a problem is suspected.

19. Medical Equipment
Extension cords may only be used with the approval of Clinical Engineering for Medical Equipment in emergency situations.
Relocatable Power Taps (Power Strips) are regulated by the Joint Commission and are not allowed in the patient care area without CE inspection & asset tag.

20. Medical Equipment
Equipment with damaged electrical cords or plugs should be immediately red tagged for repair and removed from the area to prevent use of unsafe equipment.
Staff should notify Clinical Engineering of broken equipment by entering an electronic Work Request through My IU Health Team Portal via the CE/Facilities Work Request link, or by calling (317) or from any IU Health facility.
For medical equipment emergencies after hours call (317) or

21. Utilities Systems

22. Utility Systems
To help support the overall safety of patients, visitors and staff:
Foam liners and/or specimen bags must be used to pack items being placed in pneumatic tube carriers.
Only life-support and other essential equipment should be plugged into red emergency receptacle outlets.
Life-support and other essential equipment should be plugged into red emergency receptacle outlets at all times to prevent failure during loss of normal power.

23. Utility Systems
To help support the overall safety of patients, visitors and staff:
In the event of an elevator entrapment, passengers should use the emergency phone located inside the elevator cab. This automatically provides location information to emergency responders.

24. Utility Systems
To help support the overall safety of patients, visitors and staff:
Staff should know that if the regular telephones are not working, the red telephone system should work. The number and location of red phones are located in the IU Health Emergency Procedure Guide and on My IU Health Team Portal.
In the event of a power failure, working flashlights should be available in all areas and staff should know how to call Facilities Maintenance to report the outage.

25. Emergency Management

26. Emergency Operations Plan (EOP)
IU Health employees are encouraged to report any emergency they believe would require activation of the Emergency Operations Plan (EOP) to their facility AA or to IU Health Security Dispatch (IU Health Morgan contact Administrator on Call for disruption of routine operation or Plant Operations for other issues). Some reasons for activation of the EOP are:
Loss of utilities i.e. water, electrical power, or piped gases
An external event which could bring an influx of patients or disrupt routine operations
An internal event such as a fire or building damage requiring an evacuation
A chemical release or spill affecting multiple areas
A security incident such as a hostage situation
The process for activation of the EOP can be found in the Emergency Procedure Guide (EPG).

27. EOP
When staff hears the announcement, “Disaster Alert”, all available staff should return to their home department or location (IUH Morgan staff report to staging area).
If called in for an EOP activation, staff should report to their home department or unit (IUH Morgan staff report to staging area).
Be sure to wear your IU Health ID badge at all times.

28. Emergency Procedures Guide (EPG)
Staff should be familiar with the Emergency Procedures Guide (EPG) that is designed to serve as a quick reference during emergencies.
The EPG should be centrally located in all departments.
Ensure EPG is current edition (2015 or both contain the same information).
EPGs can be ordered via Lawson (IUH Morgan EPG available through Safety Coordinator)
For specific disaster response actions, refer to the appropriate Incident Action Plan located in the EPG.

29. Command Center
A command center may be set-up to coordinate efforts during an EOP activation.
Staff should only report to the Command Center when asked to do so.
Do not report to a command center to pick up appropriate forms. Required forms are located HERE (Ensure you are using the most current form).

30. Emergency Management There are four stages of evacuation as follows:
Horizontal
Vertical
Evacuation to another building or outside
Total campus evacuation

31. Disaster Supply Box
Staff should know the location of your departmental “Disaster Box” along with its contents.
The boxes should contain emergency supplies
such as flashlights, lanterns, forms and other materials needed to ensure
the continued operation of the department during a disaster.