Strange Observations – Part 40

Continuing in a series of strange things that I have seen while consulting at hospitals…

This is not only strange… but this is morbid.

Right across the street from the entrance to the hospital ER department, is a cemetery.

Do you think that strikes some fear into people’s mind when they enter the ER for service?

Emergency Department Corridor Width

Q: What is the minimum acceptable clearance required in an Emergency Department corridor? Currently there is a crash cart stored for rapid accessibility and the distance directly in front of it is effectively reduced to slightly over 72-inches allowing enough room for a stretcher still to pass. The cart is on wheels and can be quickly easily rolled out of the way as might be needed.

A: Is the Emergency Department a suite of rooms? If yes, then you have nothing to worry about. There are no corridors inside a suite of rooms, even though what looks like a corridor is actually a communicating space. But you do have to maintain aisle width clearance and section 7.3.4.1.1 of the 2012 LSC says the minimum aisle width is 36-inches. So it looks like you have that covered with the 72-inches clearance.

However, if the Emergency Department is not a suite, then you must maintain corridor width requirements. But how wide is the corridor required to be in the Emergency Department? Well… that depends, based on the occupancy classification of the Emergency Department, and whether or not you have any inpatient sleeping rooms in the area. Section 18.2.3.4 (1) permits the clear width of a corridor to be 44-inches if the corridor is not intended for the housing, treatment or use of inpatients.

Now, before you say you don’t have any inpatients in the Emergency Department, remember that CMS has interpreted all Emergency Departments that provide observation beds must be healthcare occupancies, as they consider observation beds to be sleeping accommodations and therefore must meet inpatient requirements. So, if you have observation beds in the Emergency Department, then you must maintain corridor width of 8-feet.

 

But if you don’t have any observation beds in the Emergency Department, then 44-inches is your clear width requirement and it looks that you’ve made that.

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.

Clarification on Emergency Department Occupancy Classification

If you’ve been reading my blog postings over the past few months ( see http://keyeslife.wpengine.com/?s=emergency+department), you’ve read were I have reported that CMS has issued informal, non-public letters to the accreditation organizations (AOs) regarding the occupancy classification of emergency departments. To review how this issue started, CMS issued a letter to one of the AOs last fall (in 2016) regarding the occupancy classification of Emergency Departments. In this letter, CMS said Emergency Departments needed to be classified as healthcare occupancies. This information was then shared to the other AOs.

This set-off quite a stir in the healthcare community, as many people and organizations objected to this strict interpretation, since the 2012 Life Safety Code actually permits Emergency Departments to be classified as ambulatory healthcare occupancies.  Many free-standing Emergency Departments have already been constructed to meet ambulatory healthcare occupancy requirements, and to make physical changes after the facility has been occupied would be an unreasonable hardship.

Apparently, the objections to this rather strict interpretation have been heard, and CMS has again issued an informal, non-public communication that says they have not issued any policy regarding Emergency Department classification. Therefore, according to CMS, occupancy classification of Emergency Departments would be determined in accordance with 2012 Life Safety Code.

This means according to 3.3.188.1, an Emergency Department may be classified as an ambulatory healthcare occupancy provided it does not have sleeping accommodations for 4 or more patients on a 24-hour basis. CMS considers a bed used for 24-hour observation to be ‘sleeping accommodations’ and if the Emergency Department has 4 or more observation beds, then the Emergency Department must be classified as a healthcare occupancy.

Also, another item to consider… If you have an Emergency Department that is considered a suite and is required to be classified as a healthcare occupancy due to ‘sleeping accommodation’ rooms, then the Emergency Department would have to meet the requirements of section 19.2.5.7.2 “Sleeping Suites”. This means, where you previously may have enjoyed a suite that is up to 10,000 square feet in size, you may now be limited to just 5,000 square feet. However, take a look at section 19.2.5.7.2.3 as you may qualify to meet the requirements to bump the suite size up to 7,500 square feet or perhaps even to 10,000 square feet.

This clarification from CMS is helpful, and should go a long way to explain the occupancy classification of Emergency Departments.

CMS Interprets Emergency Departments to be Healthcare Occupancies

The following article was published today online by the HCPro newsletter ‘Healthcare Life Safety Compliance’, and is reprinted here with permission.

In a rather surprising interpretation by the Centers for Medicare and Medicaid Services (CMS), all Emergency Departments (ED) are now required to be classified as healthcare occupancies only. For many hospitals this may not be a problem, but for those hospitals that have already classified their EDs as ambulatory healthcare occupancy, they will have to make a change back to healthcare occupancy. This also affects those free-standing Emergency Departments that were designed and approved as ambulatory healthcare occupancies; according to CMS’ recent interpretation, they also must meet the requirements for a healthcare occupancy. And it appears this decision is retroactive to existing conditions.

This all came-about when the accreditation organizations (AO) submitted their revised and updated standards to CMS last fall for the change to the new 2012 Life Safety Code. One particular AO created an introduction to their Life Safety chapter and explained the differences in occupancies and gave an ED as an example of an ambulatory healthcare occupancy. CMS wrote back and said EDs cannot be ambulatory healthcare occupancies and must be classified as healthcare occupancies because they provide sleeping accommodations for patients who are on 24-hour observation.

Many of the AOs objected to this change and pointed out that the ED does not provide sleeping accommodations but rather examination rooms. Even patient-safety advocate groups like the American Society for Healthcare Engineering (ASHE) objected to this new ruling in the initial proposed rule.

“If a patient is on 24-hour observation in an ED, they are still being examined even if they are sleeping”, says Chad Beebe, Deputy Executive Director of ASHE. “It’s an entirely different staffing model than you would find in a nursing floor. It is very similar to Sleep Labs; even though the patient is sleeping, the patient is still being examined. And Sleep Labs are not required to be located in healthcare occupancies because they are providing outpatient services.”

Just like Sleep Labs, patients in an Emergency Department are considered to be out-patients and not inpatients. According to section 3.3.188.7 of the 2012 LSC, a healthcare occupancy is used to provide medical or other treatment of care simultaneously to four or more patients on an inpatient basis, where such patients are mostly incapable of self-preservation.

“How can CMS consider an Emergency Department is required to meet healthcare occupancy if the patients in the department are not even inpatients?” says Brad Keyes, owner and Senior Consultant for Keyes Life Safety Compliance, LLC. “The NFPA definition for ambulatory healthcare occupancy specifically describes emergency departments as ambulatory healthcare occupancies because they are outpatients, not inpatients. Why does CMS feel the need to depart from the NFPA definitions, that have been used in healthcare for decades?”

The financial implications by this excessive interpretation is far-reaching. Many free-standing Emergency Departments have been designed, approved and constructed in compliance with ambulatory healthcare occupancy requirements. Basic egress issues would suddenly be non-compliant, such as corridor width. Healthcare occupancies require 8-foot corridor widths for new construction, where ambulatory healthcare occupancies only require 44 inches. In healthcare occupancies, doors are required to separate the corridor from the exam rooms. In ambulatory healthcare occupancies, doors are not required. The cost to meet these new egressing requirements would be excessive.

Another difference between healthcare occupancies and ambulatory healthcare occupancies is the construction type, which identifies the combustibility and fire-resistance rating of the structural members of the building.

“A free-standing single-story Emergency Department that was constructed to ambulatory healthcare occupancy requirements, is not restricted in the construction type used to build the facility”, says Keyes. “However, that’s not true for Emergency Departments that are required to meet healthcare occupancy requirements. Unprotected wood-frame facilities and certain buildings with exterior non-combustible structural elements are not permitted to be used for healthcare occupancies.”

Converting an existing Emergency Department that has non-compliant construction type for healthcare occupancies would be very costly, if not prohibitively so.

“An additional cost may be in sprinklers”, says Keyes. “New ambulatory healthcare occupancies are not required to be protected with sprinklers, but new healthcare occupancies are. So, if the ED that was constructed to ambulatory healthcare occupancy requirements was not protected with sprinklers, it would have to when it is converted to healthcare occupancy. That will be a substantial cost to install sprinklers in an occupied facility.”

Even if the Emergency Department was constructed as a healthcare occupancy and designed to meet egress requirements for suites, that would have to change. If designed as a non-sleeping suite, the maximum size of the suite is 10,000 square feet. Now, according to CMS the Emergency Department is no longer a non-sleeping suite, but must meet the requirements of a sleeping suite which can be required to be half the area of a non-sleeping suite. That would require the installation of new barriers and doors.

“For many Emergency Departments, the cost to comply with the new CMS interpretation will be an unreasonable hardship”, says Beebe. “Facilities will have to be cited for non-compliance and then submit a waiver request. And there is no guarantee that the waiver will be approved by the CMS regional office.”

This latest interpretation by CMS seems to be in contrast to President Trump’s initiative to lower the cost of regulation. In fact, the new Administration is working to identify and repeal federal regulations that are unreasonable and costly. This interpretation by CMS seems to fit that bill.

Keyes offers an explanation why this interpretation by CMS is not made public. “CMS did communicate with those AOs with hospital deeming authority last fall regarding this interpretation, but so far, they have not notified the public”, says Keyes. “It could very well be that CMS has always believed Emergency Departments to be healthcare occupancies and they now feel there is no reason to make a formal notice, such as a Survey & Certification letter.”

“ASHE has already received reports from members that they have been cited for having Emergency Departments and hospital outpatient departments located in ambulatory healthcare occupancies or even business occupancies”, says Beebe. “The enforcement of this interpretation has already started, and will only grow when the AOs begin their enforcement as well.”

Emergency Department Classification

Q: Should Emergency Departments be classified as healthcare, ambulatory healthcare, or business occupancies?

A: According to the 2012 Life Safety Code, a typical Emergency Department (ED) may be classified as healthcare or ambulatory care occupancies, but never business occupancy. The patients brought to a typical ED are not necessarily ambulatory or put in the NFPA vernacular, “capable of self-preservation”. So that would eliminate the business occupancy as a choice.

But informal communications from CMS reveals that they do not agree with this interpretation, entirely. While the typical ED does not provide sleeping rooms, it is understood that the ED may have 24-hour observation beds. In the way that CMS thinks, they consider these 24-hour observation beds as sleeping accommodations, so the designation of healthcare occupancy is mandatory.

Now, if your ED does not have 24-hour observation beds, then it is clear the ED could be classified as ambulatory healthcare occupancy.

Other issues that hospitals may have in deciding whether to classify the ED as ambulatory care or healthcare occupancy are:

  • A 2-hour fire rated barrier is necessary to separate ambulatory care occupancy from the rest of the hospital that is classified as healthcare occupancy;
  • Exiting from the healthcare occupancy through the ambulatory has to meet all of the requirements for healthcare occupancy, unless there is a horizontal exit involved;
  • Suites are permitted in ambulatory occupancies, and according to the 2012 Life Safety Code, they are allowed to be unlimited in size, but still have certain travel distance limitations;
  • Corridors in ambulatory care occupancies are only required to be 44 inches wide in clear width;
  • As long as the ambulatory care occupancy is a single tenant, or as long as the ambulatory care occupancy is fully protected with automatic sprinklers, rooms are not required to be separated from the corridors. Therefore, there are no requirements for doors to ED exam rooms, and if they do have doors, they are not required to positively latch.

Most of the times that I have observed organizations classify their EDs as ambulatory care occupancies, it was due to the fact that the ED did not qualify as a suite as described in the healthcare occupancy chapters, but they wanted to take advantage of the 44 inch wide corridors issue, and the no-door issue permitted in the ambulatory care occupancy. That would allow them to pretty much maintain the ED similarly to a suite, with some limitations.