Hazardous ER Department

Q: In a hospital emergency department, can the corridors be 6 feet wide? Can the hospital install an 18-inch deep lockable computer cabinet in the 8 foot ED corridor?

A: Well… It depends.

If you claim the ER is a suite, then there would be no problem with a cabinet in the 8-foot wide hallway…. Because there are no corridors in a suite. What looks like a corridor in a suite is a communicating space and you would only have to maintain 36-inches clearance for aisles.

But if the ER is not a designated as a suite, then you must maintain corridor widths. But the required width of the corridor is different depending on the occupancy classification of the ER. CMS has said that Emergency Departments must be classified as healthcare occupancies (HCO) if the ER has patient observation beds. CMS’s logic on this is if patients are under observation in the ED, then they consider this patient sleeping accommodations. In this logic, then all areas providing patient sleeping accommodations must be healthcare occupancies, and the required width of the corridor must be 8-feet.

However, CMS does permit the Emergency Department to be classified as an ambulatory health care occupancy (AHCO) if the ER does not contain any patient observation beds. Then the corridor width is only required to be 44-inches wide.

But keep in mind, the maximum corridor projection permitted by CMS is 4-inches. If your ER is not designated as a suite, then you must maintain corridor widths (either HCO widths of 8-feet, or AHCO widths of 44-inches) and you cannot have corridor projections more than 4-inches, and the cabinet would not be permitted.

Storage in an Ambulatory HCO Mechanical Room

Q: I’m trying to find out particular rules regarding storage and what is allowed to be done in a penthouse. We have a new-construction Ambulatory Care occupancy. The question is not what we can’t use it for; but what we can use it for.  It is currently fully sprinkled, but not separated from the rest of the ASC with fire resistive construction. It is built and considered “unoccupied” space. So, can I put up a work bench? Can I store filters and other maintenance supplies? It has tons of room and is wide open in parts.  The rest of the building has no space at all designated for facilities maintenance; no workshop, no equipment and tool room, nothing at all.

A: NFPA codes and standards prohibit storage in a mechanical room based on specific issues, such as an unoccupied mechanical room that opens onto an exit enclosure (stairwell), or when there is fuel-fired equipment in the mechanical room. But in a general sense, there is no NFPA code or standard that specifically prohibits storage in a mechanical room as long as the room itself meets the requirements for storage. Also, access to the mechanical equipment in the room must be maintained free and clear since that is the original purpose of the room.

Section 20.3.2 in the 2012 LSC references hazardous rooms. Basically, it says any room used for storage has to meet the requirements of section 8.7 for hazardous rooms. Section 8.7 says the room has to be either protected with sprinklers (which you say it is), or enclose the room with 1-hour fire rated barriers (which you say it is not). It appears to me that you would be compliant with the 2012 Life Safety Code, but I suggest you contact your state and local authorities to determine if they have other codes and regulations that would be more restrictive.

Healthcare vs. Ambulatory Healthcare Occupancy

Q: A surgery suite (5 ORs), PACU (8 bays), and ASU (17 rooms), newly built on the 3rd floor of a business occupancy building. A 2 hour box was constructed all the way around the floor (above, below, adjacent) and it was designed to meet healthcare occupancy. These are the operating rooms not only for ambulatory surgery (same day) patients but for the hospital’s in-patients as well. How should this area be classified in regards to occupancy designation? Does the potential for a large number of in-patients in the units mean it gets classified as healthcare even if there is no overnight sleeping?

A: One may agree with your logic that as long as there are not any overnight sleeping rooms provided within the unit, it could be classified as an ambulatory healthcare occupancy. But, to take an inpatient out of the healthcare occupancy and perform surgery on them in the ambulatory healthcare occupancy seems to be contrary to the intent of having different occupancies. Is the patient an inpatient or an outpatient? If inpatient, they have surgery in healthcare occupancies. If an outpatient, they have surgery in an ambulatory healthcare occupancy.

The bottom line… You are bringing inpatients from the hospital into the surgery area, therefore the surgery area must be healthcare occupancy. From my perspective, healthcare organizations should not be taking inpatients out of healthcare occupancies to ambulatory healthcare occupancies to perform surgery on them.

Fire Barriers in Ambulatory Healthcare Occupancies -Part 2

 Q: Our ambulatory healthcare occupancy was constructed without a fire barrier separating the other business in the building. Now I have been asked to find out if we have to install a fire barrier after the unit is constructed and if there are any other options. Your comments would be appreciated.

A: Well…. From a code standpoint, you may be obligated to have two different barriers:

  1. A 1-hour fire rated barrier to separate the ambulatory healthcare occupancy from other units that are not ambulatory healthcare occupancies (i.e. physician’s offices that would be classified as business occupancies). See sections 20.1.2.1 and 20.3.7.1 of the 2000 Life Safety Code.
  2. A 1-hour rated smoke compartment barrier to subdivide your ambulatory healthcare occupancy into two compartments. Exceptions to this requirement apply if your unit is less than 5,000 square feet and the unit is fully protected with smoke detectors, or if the unit is less than 10,000 square feet if the unit is fully protected with automatic sprinklers. See section 20.3.7.2 of the 2000 Life Safety code.

If you receive Medicare & Medicaid reimbursement funds then you are obligated to comply with these codes. However, CMS does allow you to apply for a waiver if compliance with the Life Safety Code is a hardship for the organization. You cannot apply for a waiver until you are first cited for a Life Safety Code deficiency by an accreditation organization or a state agency surveying on behalf of CMS. But there are no guarantees that CMS would grant approval of a waiver request for this deficiency. Even if they did, the waiver is only valid for 3 years then you have to be cited again and then you have to submit a waiver request again. At best, it is a temporary process… not a permanent solution. My suggestion is to make plans to resolve the deficiency as soon as possible and if you get cited in the meantime, you can always submit a waiver request as part of your Plan of Correction.

Fire Barriers in Ambulatory Healthcare Occupancies – Part 1

Q: We have built a new Wellness Center with physician offices, diagnostic areas, cafe, etc. and included in the facility is an Ambulatory Endoscopy Center. A question has been raised as to whether or not this Endo Unit needs a firewall separation. Where does the Life Safety Code discuss the requirements for Endo Units? What options do we have if we do not have the requisite fire barriers?

A: You won’t find the phrase Ambulatory Endoscopy Unit (or Endo unit) in the Life Safety Code, because the code deals with different occupancy designations, not different uses within those specific occupancies. You didn’t say, but I’m guessing the Endo Unit is classified as an ambulatory healthcare occupancy, as I suspect the patient is sedated and incapable of self-preservation. Another assumption is made that this unit is an outpatient unit, thereby supporting the thought it is an ambulatory healthcare occupancy. It appears you have an outpatient endoscopy unit that serves 4 or more patients that are incapable of self-preservation. That makes it an ambulatory healthcare occupancy designation. Ambulatory healthcare occupancies are required to be subdivided into at least 2 separate smoke compartments with a 1-hour fire rated barrier. The 1-hour fire rated barrier must extend from the floor to the floor or roof slab above, and openings (i.e. doors) must be at least 1¾ inch thick, solid-bonded wood core and be self-closing. Exceptions to the subdivision into two smoke compartments are if the ambulatory healthcare occupancy is less than 5,000 square feet and fully protected with smoke detectors; or if the ambulatory healthcare occupancy is less than 10,000 square feet and protected throughout by automatic sprinklers. Ambulatory healthcare occupancies must be separated from other occupancies (i.e. business occupancies) by a 1-hour fire rated barrier that extends from the floor to the floor or roof slab above. Doors in this barrier must be ¾ hour fire rated, self-closing, and positive latching. There are other fire barriers that could be part of the Endo Unit, such as fire barriers separating hazardous areas from occupied areas, and barriers separating exit enclosures from occupied areas.

ASC Fire Alarm Testing

Q: What section of NFPA 72 (the National Fire Alarm Code) requires ambulatory surgery centers to perform testing of their fire alarm system on a quarterly basis? Do devices that require annual testing have to be divided and have the service contractor do 25% of them each quarter? My organization would like to know the specific identifier so that the requirement may be referred to.

A: The quick answer is there is no requirement in NFPA 72 (or any other NFPA standard) that requires quarterly testing of the fire alarm system for ASC classified as ambulatory care occupancies. Section 20.3.4.1 of the 2000 edition of the LSC requires compliance with section 9.6. Section 9.6.1.4 requires compliance with NFPA 72 (1999 edition) for testing and maintenance. NFPA 72, Table 7-3.2 discusses the frequency of testing and inspection for each component and device of the fire alarm system. While there are a few items that require quarterly testing (such as water-flow switches on sprinklers system, which actually comes from NFPA 25, and off-premises emergency notification transmission equipment), for the most part, annual testing is required on all initiating devices, notification devices, and interface devices. You do not have to divide the components that require annual testing into four groups and have your service contractor perform testing on 25% of the devices on a quarterly basis. Actually, this can be troublesome for larger organizations if the service contractor fails to test the devices during the same quarter each year. Most accreditation organizations require the annual test to be performed 12 months from the previous test, plus or minus 30 days.

Ambulatory Healthcare Occupancies

Q: How do I determine if our outpatient facility is an ambulatory healthcare occupancy?

A: Based on what the 2000 Life Safety Code says, an ambulatory healthcare occupancy is a building or portion thereof used to provide services or treatment simultaneously to four or more patients that: 1) Provides on an outpatient basis, treatment for patients that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others; or 2) provides on an outpatient basis, anesthesia that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others. Ambulatory healthcare facilities shall be separated from other tenants and occupancies by walls and barriers not less than 1-hour fire resistance rating. The ambulatory healthcare facility shall be divided into not less than two smoke compartments. Facilities of less than 5,000 square feet and protected with approved automatic smoke detection system do not have to be subdivided, and facilities of less than 10,000 square feet and protected throughout by an approved, supervised automatic sprinkler system do not have to be subdivided into two smoke compartments. Not less than 15 net square feet per ambulatory healthcare facility occupant shall be provided within the aggregate area of corridors, patient rooms, treatment rooms, lounges and other low hazard areas on each side of the smoke compartment for the total number of occupants in adjoining compartments. I also bring to your attention that in their proposed rule to adopt the 2012 Life Safety Code (issued in April, 2014) CMS stated they will seek to change the rules that govern ambulatory healthcare occupancies. Currently it requires four or more persons incapable of self-preservation to be classified as an ambulatory healthcare occupancy. If CMS gets their way that will be reduced to 1 or more persons incapable of self-preservation will require an ambulatory healthcare occupancy, and all of the above LSC references would apply. The big thing here is the 1-hour fire rated separation barriers and the ambulatory healthcare area divided into at least two smoke compartments. That would be a substantial cost to retroactively install those barriers after the area is occupied.

Fire Drills in an ASC

images0XCM788RI spoke at an Infection Control conference last week in St Louis, sponsored by the Excellentia Advisory Group. There were 13 different presentations made but mine was the only one that was not traditionally an IC subject matter. I was asked to make a presentation on how the Life Safety Code relates to Infection Prevention in the Ambulatory Surgical Centers. At first, I was reluctant to accept this speaking engagement because I was not sure how I was going to draw the connection between compliance with the Life Safety Code and how it actually impacts the Infection Prevention program in an ASC. But, I did accept the invitation and I researched the LSC and came up with a what I think was an interesting presentation.

Keep in mind, my audience was a room full of RNs who typically do not have any Life Safety Code compliance experience. So, I decided to take the approach that compliance with the LSC is just basic patient safety compliance, and identified many of the requirements that surveyors would be looking for.

At the end of my presentation I had time to take a few questions. One lady asked if they had to activate the building fire alarm system when they conducted a fire drill. I replied that yes, technically they would, since section 20.7.1.4 of the 2012 LSC requires it. They said that is a problem since the ASC shares the building with other tenants who are not part of their healthcare network.

I replied that they had a few of options: 1) They could coordinate with all of the other tenants prior to the fire drill alerting them of the pending alarm. The other tenants could conduct their own drill at that time if they chose; or 2) They could investigate to see if the fire alarm control panel can bypass the occupant notification appliances in the other tenants during their drill; or 3) They could conduct a risk assessment that identifies the hardship involved in sounding the building fire alarm system and conduct the drill without activating the alarm. This would have to be reviewed and approved by the ASC safety committee, and possibly a surveyor would accept that.

I asked if they thought they could use one of those scenarios, and they thought #3 would be the only possible solution. I asked why, and they said there was a massage parlor directly above their ASC and they didn’t believe they could get the cooperation from them and all the other tenants so they could activate the fire alarm system when they conducted a fire drill each quarter. I replied that I thought they had a pretty good case for a risk assessment since nobody wanted to see clients from the massage parlor escaping down the stairs during a fire alarm.

Uhm… the strange things I see (or don’t see) in this business.

All-in-all, I thoroughly enjoyed my day at the conference and I got to meet many interesting people.

New vs. Existing Construction for Ambulatory Healthcare Occupancies

A reader asked me recently what the Life Safety Code differences were between a new construction ambulatory healthcare occupancy, and an existing construction ambulatory healthcare occupancy. I did not immediately know, so I took the time to research this and I was surprised to learn what the differences (or non-differences) were.

The differences between new construction and existing construction of ambulatory healthcare occupancies are not monumental, but rather subtle. According to the 2000 Life Safety Code, here are some comparisons:

Description Chapter 20 New Construction Chapter 21 Existing Construction
Construction Type No restrictions for 1 story facilities; Building of two or more stories limited to Type 1 (443), Type I (332), Type II (222), Type III (211), Type IV (2HH), Type V (111). Type II (000), Type III (200), and Type V (000) are permitted if the entire building is protected with sprinklers.  Same
Occupant Load 100 square feet/person Same
Special Locking Arrangements Only permitted on exterior doors Same
Clear Width of Corridor 44 inches Same
Travel Distance between room and exit 100 feet Same
Travel distance between any point in a room and exit 150 feet Same
Travel distance increased for sprinklered buildings 50 feet Same
Emergency Power from Generators as per NFPA 99 Required when general anesthesia or life-support equipment is used. Same
Hazardous Areas Must meet the requirements of 8.4 and be protected with sprinklers, or protected with 1-hour construction Same
Anesthetizing Locations Must be protected in accordance with NFPA 99 Same
Fire alarm systems Manually initiation required Same
Portable fire extinguishers Required Same
Sprinkler System Not Required Same
Corridors Openings in corridor walls such as mail slots and pass-through windows permitted in windows and doors provided the opening is not more than 20 square inches. The opening may increase to 80 square inches if the room is protected with sprinklers. No Restrictions/No Requirements
Subdivision of Building Space Ambulatory healthcare occupancies must be separated from other occupancies with 1-hour fire rated barriers with ¾ hour fire rated doors Same
Smoke Compartmentation The ambulatory healthcare occupancy must be divided in to not less than two smoke compartments. Facilities less than 5,000 square feet that are protected by a smoke detection system are exempt. Facilities less than 10,000 square feet and protected by sprinklers are exempt. Same
Smoke Compartment Size Not less than 15 square feet area (net) must be provided for every occupant in the ambulatory healthcare facility on either side of the smoke compartment barrier. Smoke compartments are limited to 22,500 square feet in size. Travel distance to reach a smoke compartment barrier doors must not exceed 200 feet. No Restrictions
Fire Drills Required quarterly on all shifts Same
Combustible decorations Prohibited, unless they are flame retardant Same
Portable Space Heating Devices Prohibited, unless the heating elements do not exceed 212°F and only used in non-sleeping staff and employee areas. Same

 

 

Outpatient Centers and Clinics

Q: We have multiple outpatient centers and clinics, and I would like to know how the Life Safety Code classifies them. Are they all treated as business?

A: The Life Safety Code defines different occupancies by the level of care and/or activities that take place in them. A hospital may have many different occupancy classifications, or it may have only one… it’s the organization’s decision. Here is a run-down on the most common occupancy classifications found in healthcare today, and their requirements:

Healthcare Occupancy

An occupancy used for purposes of medical care or other treatment where four or more persons are incapable of self-preservation; and provides sleeping accommodations for those patients.

Ambulatory Care Occupancy

An occupancy used for purposes of medical care or other treatment on an outpatient basis, where four or more persons are incapable of self-preservation, and does not provide sleeping accommodations.

Business Occupancy

An occupancy used for the transaction of business other than mercantile.

So, to answer your question, an outpatient center and clinic could very well be ambulatory care occupancy or it may be business occupancy; it all depends on what level of care and treatment is provided. It is permissible to have more than one occupancy in the same building, provide appropriate fire rated barriers separates the occupancies. A 2-hour fire rated barrier is required to separate a healthcare occupancy from any other occupancy, and a 1-hour fire rated barrier is required to separate different occupancies that are not healthcare.

There are distinct requirements for each occupancy, but the requirements are less for ambulatory care compared to healthcare, and they are even less for business as compared to ambulatory care. So there is an advantage to the organization if the clinic was classified entirely as business occupancy. However, you may not have 4 or more persons incapable of self-preservation in a business occupancy, so make sure you are in synch with that.

Also, CMS considers all ambulatory surgical centers (ASC) to be ambulatory care occupancies regardless of the number of patients incapable of self-preservation, and they also consider end stage renal disease (ESRD) dialysis centers to be ambulatory care occupancies if they are located on a floor other than the level of exit discharge, or if they are contiguous to a high-hazard occupancy. Be aware that in their proposed rule to adopt the 2012 Life Safety Code, CMS has indicated that they intend to classify facilities that have 1 or more patients incapable of self-preservation as an ambulatory care occupancy. Whether they will adopt that as a final rule is unclear, but you should be aware of the possibility.