Standard Operating Procedure (SOP) for Code Red

Objective:
To provide a clear and standardized process for handling Code Red situations, ensuring the safety and well-
being of all patients, staff, and visitors within the hospital premises in case of a fire or fire-related emergency. This
includes integrating the R.A.C.E (Rescue, Alarm, Confine, Evacuate) and P.A.S.S (Pull, Aim, Squeeze, Sweep)
fire safety techniques into the response process.

1. Purpose

This SOP outlines the procedures for responding to a Code Red emergency, defined as a fire or smoke incident
within the hospital. It aims to facilitate immediate action, ensure effective evacuation, and minimize risk to life and
property while incorporating fire safety methods R.A.C.E and P.A.S.S to optimize the emergency response.

2. Scope

This procedure applies to all hospital staff, patients, and visitors. It covers all hospital areas, including patient
rooms, public spaces, staff areas, and medical units.

3. Code Red Definition

A Code Red is declared when there is an indication of fire or smoke within the hospital. This includes any signs
of fire or when the fire alarm is activated.

4. Procedure

4.1 Identification of Fire

 Signs of Fire: Smoke, unusual heat, flames, or a fire alarm.

 Immediate Action:

o Alert the nearest fire alarm system if not already activated.

o Call the hospital emergency number (e.g., extension 111 or emergency line).

o Report the fire's location (building, floor, room number) to the control room or emergency
response team.

4.2 Activate the Fire Alarm

 If the fire alarm is not already triggered, manually activate the nearest fire alarm system.

 Announce Code Red over the hospital’s PA system, clearly indicating the location of the fire.

4.3 Evacuation

 Patient Evacuation:

o Ensure that patients, especially those who are critically ill or immobile, are evacuated first. Use
evacuation equipment (e.g., wheelchairs, stretchers).

o Assign staff to accompany patients to the designated safe zones.

o Ensure patients are moved to assembly points away from the fire hazard.

 Staff and Visitor Evacuation:

o Evacuate all non-essential personnel and visitors following the designated evacuation routes.

o Ensure staff remain at their designated posts to assist with evacuation.

4.4 Containment of Fire (R.A.C.E)

 R.A.C.E is the standard procedure for managing fire situations in hospitals:

o R - Rescue: Quickly remove patients, staff, and visitors from the immediate danger area.

o A - Alarm: Activate the fire alarm system to alert the entire hospital and call emergency
services (fire department).

o C - Confine: Close all doors and windows to prevent the spread of smoke and fire.

o E - Evacuate: Evacuate personnel and patients from the affected area, following the
designated routes and using evacuation aids for those with mobility challenges.

4.5 Using Fire Extinguishers (P.A.S.S)

 If the fire is small and contained, staff may use a fire extinguisher. The proper technique to use a fire
extinguisher is P.A.S.S:

o P - Pull: Pull the pin on the fire extinguisher to break the tamper seal.

o A - Aim: Aim the nozzle at the base of the fire, not at the flames.

o S - Squeeze: Squeeze the handle of the extinguisher to release the fire suppressant.

o S - Sweep: Sweep the nozzle side to side at the base of the fire until it is completely
extinguished.

 Note: Never use a fire extinguisher on a large or spreading fire. Evacuate immediately and wait for
professional fire services to handle the situation.

4.6 Communication

 Maintain constant communication with the control room, emergency team, and fire department.

 Provide clear information about the fire's location, status, and any special considerations (e.g.,
hazardous materials, blocked exits).

 Update hospital leadership on the situation and progress of evacuation efforts.

4.7 Roles and Responsibilities

 Nurses and Clinical Staff:

o Evacuate patients to the nearest safe zone.

o Provide assistance to patients with mobility issues.

 Security Personnel:

o Manage the flow of people, ensuring that emergency exits are clear.

o Assist fire department personnel with access to the building.

 Fire Response Team:

o Ensure all fire suppression systems are operational.

o Coordinate with the local fire department upon arrival.

 Administrative Staff:

o Monitor hospital communication systems and assist in organizing evacuation efforts.

4.8 Fire Department Notification

 Call the local fire department immediately after identifying the fire.

 Provide clear details about the fire's location and severity.

 Fire Safety Check: Ensure the fire is completely out, and no other hazards exist.

 Debriefing: After the fire is contained, conduct a debriefing session to assess the response. Identify
areas for improvement in the procedure.

 Documentation: Document the details of the incident, including the time of alarm, actions taken,
evacuation procedures, and any issues encountered.

6. Training and Drills

 R.A.C.E and P.A.S.S Training:

o Regular fire drills should include the practice of the R.A.C.E (Rescue, Alarm, Confine,
Evacuate) and P.A.S.S (Pull, Aim, Squeeze, Sweep) procedures to ensure staff are proficient in
managing fire emergencies.

o Fire extinguisher training should be conducted annually.

 Regular Fire Drills:

o Regular fire drills will be conducted to ensure staff are familiar with the Code Red procedures,
including the use of R.A.C.E and P.A.S.S methods.

o All new employees must receive fire safety training, including these techniques, during their
induction period.