Sprinklers in Patient Room Lockers

Q: Are sprinklers required in patient room lockers for existing facilities?

A: No… Section 8.1.1 (7) of NFPA 13-2010 says furniture not intended for occupancy is not required to be sprinklered.

Staff Sleep Room

Q: Within our X-ray department we have a room (7 1/2 ft. by10 ft.) that was our dark room for film reading years ago. We would like to make this a sleep room for staff that get called in. It has a sprinkler head; if we install a sounder base detector can we make this a sleep room and be compliant?

A: Sleeping with the old X-ray developing chemicals….? What a lovely thought.

Yes, I think you can convert this room to a staff sleep room. Your thought of putting in a smoke detector with an occupant notification device is good, but let’s look at the other items that may be needed.

First you need to confirm which occupancy chapter you need to comply with. Staff sleeping rooms is not covered under the Healthcare occupancy chapters, so you would consider “Lodging or Rooming Houses” occupancy or “Hotels or Dormitories” occupancy chapter. Reviewing the definitions of each, “Hotels or Dormitories” occupancy chapter is for 16 or more people, and “Lodging or Rooming Houses” occupancy chapter is for no more than 16 people. So, I would say that you need to follow “Lodging or Rooming Houses” occupancy chapter, and specifically, chapter 26 for new construction.

Section 26.3.4.5.1 of the 2012 Life Safety Code requires single-station smoke alarms must be installed in every sleeping room. So, according to this requirement, you would need to install a single-station smoke alarm, that has an annunciating device as you suggested. Some AHJs allow hospitals to install a building smoke detector in lieu of a single-station smoke alarm, but be aware not all AHJs see it that way.

Section 26.3.5.1 requires the sleeping room to be separated from the corridor by smoke partitions. So that means there cannot be any louvers in the door or walls.

Section 26.3.5.7 requires the door to the sleeping room to be self-closing (i.e. door closer) if the building is not fully protected with automatic sprinklers.

Section 26.3.6.1 requires the sleeping room to be protected with sprinklers, as you mentioned.

According to section 26.2.3.5.1, the door to the sleeping room cannot be locked against the means of egress. But section 19.2.2.2.4 covers that in depth and only allows certain exceptions to door locks. Keep in mind that section 7.2.1.5.10.2 does not allow the installation of deadbolt locks that are separate from the latch-set hardware.

As always, have this plan reviewed and approved by an architect and then obtain necessary approvals from your state and local authorities.

That should do it….

Wood-Frame Addition

Q: Years ago, our state health department approved an addition to a hospital that I supervise. The addition is wood framed, not sprinkler protected, and does not have the required 2-hour fire barrier separation (yes, I’m serious). Recently, sprayed-on fire proofing began to fall from the deck. After consultation, we’ve decided the best course of action is to add complete sprinkler protection to this area. This is a costly project and will take time for approval. What are your thoughts on implementing some sort of ILSM? There is no egress blocked, or obstructed, but this is an area where there are MRI machines and I believe the wood framing with no sprinkler and fire proofing issues can be a serious concern.

A: Wow… that is a serious problem. You did not say what your Construction Type is. Since it involves wood-frame, it has to be one of the following:

  • Type III (211) with sprinklers
  • Type IV (2HH) with sprinklers
  • Type V (111) with sprinklers

But you say it does not have any sprinklers? Yeah… that’s serious problem. And there is no 2-hour fire-rated vertically aligned barrier to separate this non-compliant construction type from the rest of the hospital? That means the rest of the hospital is also now non-compliant.

You absolutely need to assess this issue for ILSMs and document your assessment. The whole hospital is now out of compliance with the Life Safety Code regarding Construction Type (see Table 18.1.6.1 of the 2012 Life Safety Code). When there is no proper 2-hour fire rated vertically aligned barrier separating different construction types, then the lesser construction type prevails, and the rest of the hospital is not permitted to have this type of construction type.

You need to get professional help. Contact your architect, or a different architect if the one you currently use got you into this pickle. Discuss this with your CEO and tell him/her that you have three serious issues that will require funds:

  • Reapply the failing fire-proofing
  • Install sprinklers in the addition
  • Create a 2-hour vertically aligned barrier to separate the different construction types.

Develop a plan and time-line to implement all of these changes and improvements, but you need to discuss this with your architect, and before you do any construction, you need to submit a plan to the state and local authorities for their review.

Please understand that if you fail to resolve these issues, your next survey could end up being a Conditional Level Finding, based on the seriousness of the deficiencies.

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?

Temperature and Humidity Log

Q: How often are we required to log the room temperature, humidity levels, and air changes in our OR’s? Is this required daily, each shift, hourly? What about the other rooms like Sterile Processing and others, how often do we need to log them?

A: It depends on your accreditation organization, and to a lesser extent, the surveyor.

For Joint Commission, their standard EC.02.05.01, EP 15 says in critical care areas (i.e. operating rooms, special procedure rooms, isolation rooms, sterile supply rooms, etc.) the ventilation system must provide appropriate temperature, humidity, air-pressure relationships, and etc., based on the edition of the FGI guidelines used at the time of design. This standard does not say how often these factors need to be checked. But there are some other professional organizations such as AORN and CDC that offer opinions on how frequent. Joint Commission surveyors will expect the hospital to have adopted some frequency that is consistent with these other professional organizations, or at least have conducted a risk assessment to determine how frequent these issues need to be checked and logged.

For non-critical care areas, such as soiled utility rooms and clean utility rooms, incorrect air pressure relationships would be scored under EC.02.06.01, EP 1, but this standard is like EC.02.05.01 in that it also does not say how frequently these rooms need to be checked. Again, surveyors would expect you to follow professional organization guidelines or your own risk assessment for testing frequency.

If you’re HFAP accredited, standard 11.07.03 covers all temperature, humidity and air-pressure relationship requirements, and similar to Joint Commission, HFAP does not specify the frequency of checks. They also identify AORN and FGI Guidelines as standards to follow, but they will accept a facility-based risk assessment to determine testing frequencies, within reason.

It is up to the individual surveyors to determine if your risk assessment is acceptable and reasonable. If they believe it is, then you should be fine. If they do not feel it is acceptable, they may discuss this issue further and a finding may be cited.

As far as DNV goes, I believe they are similar to the above.

Strange Observations – Part 39

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

Okay… this was not taken at a hospital. This AC condensing unit was suspended from 2x4s for a restaurant in a small town in Iowa.

Ugh. Being a former HVAC guy, this makes my skin crawl.

Forward this picture to your HVAC contractor and let him have a good laugh today.

If you know where this was at, send my an email.

Gas Storage Ventilation

Q: In the 1999 Edition of NFPA 99, it mentions for medical gas storage systems more than 3,000 cubic feet, if the door opens to an exit access corridor, louvered openings shall not be used and a mechanical ventilation system shall be required. I cannot find that requirement in the 2012 edition of NFPA 99 regarding not using a louvered door in an exit access corridors. Has it been eliminated, or am I just missing it? If it was eliminated, do you know why?

A: In a way they eliminated it and in another way they did not. Yes, they did delete the language that says doors that open onto an exit access corridor cannot have louvers for ventilation. But that does not mean you can now have louvers in doors to exit access corridors. Section 5.1.3.3.2 of the 2012 NFPA 99 is the section for central storage in quantities greater than 3,000 cubic feet of compressed medical gas, and for gas manifold systems.

You will notice that ventilation requirements are no longer under section 5.1.3.3.2. You will find ventilation requirements for medical gas storage under section 9.3.7, and specifically section 9.3.7.5.2 describes natural ventilation which now limits the ventilation openings to be directly to the outside atmosphere without ductwork. This precludes the possibility of louvers in a door to an exit access corridor.

And, NFPA 99 requires a fire-rated door for medical gas storage rooms and gas manifold rooms. Louvers are not permitted in fire-rated doors.

There is still an option of using natural ventilation or mechanical ventilation, and plenty of rules for both.

Strange Observations – Part 36

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

 

Oh gross….

How would you like to have to use an eyewash station and this is what the hospital expects you to place your face into… Yuck.

Even though the eyewash station is in a mechanical room, you still have to test it weekly and maintain it.

Remember what I said in the July 5 ‘Strange Observations – Part 33’ posting? Equipment rooms are out-of-sight / out-of-mind for most people and no one is assigned to keep it safe. Stuff like this is the result.

 

Equipment in an Alcove

Q: We have an alcove in our surgery center that we are wanting to place patient refrigerator, ice machine, coffee pot. Currently there isn’t a door- it is an alcove. Is this acceptable or do these items need to be behind a door? Our surgery center has badge access, but this is in an area where patient family members are allowed.

A: If the equipment in the alcove is truly out of the required width of the corridor, then I don’t see any problem with it. Just because it is a refrigerator, ice machine or coffee pot should not make a difference. These items are not considered to be hazardous so they are not required to be kept in a designated hazardous room.

Now, if the surgery center is a suite of rooms, then of course there are no corridors inside a suite, and maintaining a certain corridor width is not required.

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.