I was recently an interested bystander in a group discussion concerning the proper testing and inspection of a battery powered emergency light fixture located in an operating room. A question was raised as to what the testing and inspection frequency should be for those devices. The person who provided the initial response pointed out that The Joint Commission already made an interpretation on this subject in the June 2007 issue of “The Environment of Care News”. While the EC News is not considered an official interpretation from The Joint Commission, it is an indication on how they survey hospitals on particular issues. [The only ‘official’ interpretations from The Joint Commission are from one of the following sources: 1) The Joint Commission standards; 2) The Joint Commission publication “Perspectives”; 3) The Joint Commission Frequently Asked Questions (FAQs) posted on their website.]
In the June 2007 issue of EC News, The Joint Commission states that battery lighting devices in an anesthetizing location (i.e. operating rooms) in existing healthcare occupancies are considered to be task lighting rather than emergency lighting since they are intended to maintain a minimum level of illumination during the period of power interruption and the establishment of emergency power. They are not considered illumination of the means of egress in that location. The Joint Commission encourages the health care organization to identify them as task lights and determine the appropriate inspection and maintenance procedures and frequency to assure reliable operation when needed.
While I respect the individuals who were involved in this discussion, I don’t see the issue that same way. First of all, why do we tend to go to The Joint Commission as if they are the final authority on all issues concerning Life Safety in healthcare organizations? While they are the largest accreditor of healthcare organization, they are not the final authority, since they are not the only authority for healthcare organizations. The typical healthcare organization may have as many as 5 or 6 different authorities that enforce the Life Safety Code at their facility:
- The state authority on design and construction
- The state fire marshal
- The local fire inspector
- The healthcare organization’s accreditor
- The federal agency on Medicare & Medicaid: CMS
- The healthcare organization’s liability insurance company
No one authority having jurisdiction (AHJ) over-rides another AHJ. If one AHJ wants to interpret the Life Safety Code a specific way, that does not mean the other AHJs have to do so as well.
Normally, battery powered emergency lights would require monthly 30-second tests and annual 90-minutes tests to ensure the batteries are charged. This requirement is found in section 7.9.3 of the 2000 Life Safety Code, but it specifically says it applies to required emergency lighting. The requirement to have battery powered emergency lights in operating rooms is found in section 3-188.8.131.52 of NFPA 99, 1999 edition. But only new healthcare occupancies are required to comply with this requirement, according to section 184.108.40.206 of the 2000 LSC for new healthcare occupancies; this is not found in the existing healthcare occupancy chapter 19. And Joint Commission did say “existing” healthcare occupancies in their interpretation. This implies that battery powered emergency lights in existing operating rooms are not required, and therefore are not subject to the testing requirements in section 7.9.3.
But what date does “existing” apply? In this case, it would be when the hospital had to comply with the 1994 edition of the LSC, which referenced the 1993 edition of NFPA 99. The 1993 edition of NFPA 99 was the first edition to require emergency lighting in anesthetizing locations. This means, for Joint Commission accredited hospitals, the term “existing” is any date prior to January, 1994. So if the battery powered lights were installed since January, 1994, they would be considered “required” and have to be tested monthly and annually.
Ironically, while The Joint Commission did adopt the 1994 edition of the LSC, the federal agency CMS (or the fore-runner of CMS) never did. They went straight from the 1985 edition to the 2000 edition on March 11, 2003. While the 1985 LSC did reference NFPA 99, it appears to me that the requirement to install battery powered emergency lights in anesthetizing locations did not appear until the 1993 edition of NFPA 99.
If a facility manager wanted to take the time to ask each of their AHJs how they interpret if the battery powered light fixture in their operating rooms are required or not, that would be one way to decide. But even if all but one AHJ says the light is not required an one AHJ says it is required, then the organization is obligated to comply with the most restrictive interpretation, and test the fixture monthly and annually.
My advice is to determine what the most restrictive interpretation would be and follow that. In this case, that would mean the battery powered emergency lights would have to be tested monthly and annually.