Exit Doors From OR

Q: Are operating rooms required to have two (2) exit doors? I have not seen this room but am under the assumption it is between 400 and 500 square feet.

A: According to section 18.2.5.5.2 of the 2012 Life Safety Code, non-sleeping rooms of more than 2500 square feet must have not less than two exit access doors remotely located from each other. Since the operating room you described is 400 to 500 square feet, I would say you are under the threshold for having to meet the requirement to have two doors to the corridor.

Now, if the Surgery area is a suite, there would not be a requirement for two exit access doors until you reached 2500 square feet total for the entire suite, which would include the operating room.

Doors to Operating Rooms

Q: We have two open-heart OR’s. Each has a full 42″ wide door leaf that open to the corridor, and each has a 3’0″ door in the rear of the OR that opens into a central sterile core. The OR walls other than the corridor side are not labeled as a fire/smoke barrier on the life safety drawings. The main OR entrance door that opens into the corridor has a door closer, is rated, and has latching hardware. My question is: The 3′ 0″ doors opening into the sterile core have closers but do they have to be fitted with latching hardware?

A: Not necessarily, provided the sterile core area is qualifies as a room or a suite-of-rooms. What does the life safety drawings say about the sterile core area? Is it classified as a suite? If so, then you should be fine without a latching door between the OR and the sterile core area.

However, if the life safety drawings clearly identify the internal walls of the sterile core area as corridor walls, then the door between the OR and the sterile core area would have to latch. Remember: All corridor doors must latch.

My guess is, the sterile core area probably qualifies as a suite-of-rooms (see section 19.2.5.7 in the LSC) or if small enough, it may qualify as a simple room. As long as the 3’0” door from the OR does not open onto a corridor, then it does not need to latch.

Operating Room Fire Drills

Q: Back in March 2016, you answered a reader’s question that fire drills are not specifically required for operating rooms. While reviewing NFPA 99-2012, I came across a section that states that fire exit drills must be conducted annually or more frequently as determined by the applicable building code, Life Safety Code, or fire code. Does this mean we must conduct fire drills in each of our operating suites every year?

A: Your observations are excellent. Back in March, 2016, there were no requirements to conduct a fire drill in Surgery. Now, after CMS adopted the 2012 edition of NFPA 99, there is. As you pointed out, section 15.13.3.10.3 of NFPA 99-2012, does require an annual fire drill for the operating room and surgical suite personnel.

However, the code does not say a fire drill has to be conducted in each operating room. The purpose of a fire drill in surgery is to provide education and training for staff. Therefore, my suggestion is to schedule the annual fire drill when there are no scheduled surgeries, and as many staff as possible can attend. You begin by conducting an education session on what the expectations are if a fire was discovered in the operating room. You can have different scenarios as the circumstances dictate. Then conduct a drill to see if the staff performs satisfactorily. If you have lots of staff, then utilize multiple operating rooms, and have multiple observers.

Mobile OR Trailer

Q: A hospital is building a small addition that will serve as a corridor to a mobile OR unit. ICC construction type of addition is I-B. The mobile OR will be attached to this corridor with a water tight seal. I am researching this issue based on the IBC and IFC, but was hopeful you could help me with the Life Safety Code and best practices when it comes to issues such as connection of fire alarm system and rating of doors between the mobile OR and the new corridor and/or the main hospital.

A: What I can tell you would likely be the same thing that your design professional is telling you. Let’s examine three distinct issues concerning hospitals, additions and trailers:

Occupancy Classification

What occupancy classification have you designated the OR trailer? Healthcare occupancy? Ambulatory healthcare occupancy? That would drive the classification of the addition to connect the hospital to the trailer. If the OR trailer occupancy classification is the same as the addition and the area of the hospital here it connects to, then there would not be a requirement for a 2-hour fire rated barrier separating occupancies. However, if the occupancy classification is different between the hospital and the addition, or if the occupancy classification is different between the addition and the OR trailer, then a 2-hour fire rated barrier is required.

Building Construction Type

You say the addition is ICC Type I-B which is comparable to NFPA 220 Type II (222) construction type. When a healthcare occupancy building connects to another building with a construction type that is less that what the first building’s construction type is, it must have a 2-hour fire rated vertical barrier separating the different construction types. Trailers are typically not constructed to meet the Type II (222) construction type of hospitals. Otherwise, they would likely be too heavy to transport on wheels. That means the construction type of the trailer is likely going to be less than the Type II (222) of the addition, and a 2-hour fire rated barrier is required to separate the addition from the trailer. This can be done at the end where the addition connects to the trailer. What about the construction type for the trailer? Since it houses patients, it has to comply with the construction type requirements found in chapter 18 for healthcare occupancy and/or chapter 20 for ambulatory healthcare occupancy. This means the trailer may have to be protected with sprinklers. How are you going to connect fire protection water to a portable trailer? You may be able to utilize a clean agent fire suppression system in lieu of water-based sprinklers, but which clean agent is suitable in a  location where a patient is incapable of self-preservation?  I’m no expert on fire suppression systems, but I suspect FM-200 and other clean agent  suppression systems are not suitable for this application. What does your state agency in charge of hospital construction say about this?

Means of Egress

You say the addition is going to serve as a corridor between the hospital and the OR trailer. Is it designated a corridor? If so, then the OR trailer must be separated from the addition because patient treatment activities are not permitted to be open to the corridor. What about exiting? If the addition is a corridor, there must be an exit near the end of the corridor where the OR trailer connects to the addition. Otherwise, you would have a long dead-end corridor, and chapter 18 of the LSC does not allow a dead-end corridor greater than 30 feet. Is it possible to designate the addition and the OR trailer as a suite of rooms? That would help with corridor clutter, as if the addition is a corridor (and not a suite) then you must maintain 8 feet clearance if the addition is a healthcare occupancy. A suite designation may not be possible depending on the travel distance from the furthest point in the OR trailer to a door in the hospital to an exit access corridor, as that is limited to 100 feet.

But what about exiting from the OR trailer? You will need stairs with handrails on both sides of the stairs even if you are using a lift system to raise the patient into the trailer. As far as connections for fire alarm system, I would be surprised if the manufacturer of the OR trailer does not have a recommendation. You would need to have all of the required fire alarm occupant notification devices as well as the initiation devices connected to the main hospital fire alarm system. I have dealt with issues involving healthcare trailers before (although this is the first time I’ve heard of a portable OR) and they are a challenge. Be aware that if you only get your state and/or local AHJ to approve the installation, you may still have a problem with your accreditor and/or your state CMS agency. It would be best to discuss this project with every AHJ you have to determine what they are going to require that you must install.

 

Fire Drills in Operating Rooms

Q: What are the requirement for operating room fire drills per Joint Commission, CMS, and AORN? Are operating room fire drills required to evacuate patients?

A: I cannot speak to what AORN suggests for fire drills, but keep in mind their standards are voluntary since they are a professional organization and not an authority having jurisdiction. On the other hand, CMS and Joint Commission’s standards are regulatory compliance and they are not optional; you must comply with them.

Joint Commission says the following under standard EC.02.03.03 for fire drills:

  • Drills are conducted once per shift per quarter in buildings defined as healthcare occupancy
  • Drills are conducted quarterly in buildings defined as ambulatory health care occupancy
  • Evacuation of the patients during the drill is not required
  • In buildings leased or rented by the hospital, drills are only required in the areas that the hospital occupies
  • In freestanding buildings classified as business occupancies, drills are conducted once per every 12 months
  • At least 50% of the drills are unannounced when quarterly fire drills are required
  • The conditions for fire drills are varied, and the drills are held at unexpected times
  • During fire drills, staff participate in the drill in accordance with the hospital’s fire response plan
  • Drills that are conducted between the hours of 9:00 pm and 6:00 am may use an alternative method to notify staff instead of activating the audible alarms of the fire alarm system
  • After the drill, the drill must be critiqued to evaluate the fire safety equipment, the fire safety building features, and the staff’s response to the drill. This evaluation must be documented.

CMS refers to the Life Safety Code, and in addition to the above, section 19.7.1 of the 2012 Life Safety Code says the following:

  • Fire drills in healthcare occupancies must include the transmission of a fire alarm signal
  • Fire drills in healthcare occupancies must simulate emergency fire conditions
  • Bedridden patients are not required to be moved during drills

All of the above would apply to any and all drills conducted at the healthcare facility, including those conducted in the operating rooms.

So, to answer your specific question, for fire drills in an operating room, the above regulations would require you to do the following:

  • Conduct fire drills in operating rooms and ensure that staff participate in the drill in accordance with your fire response plan. This may mean they are engaged in a drill that originates in their particular room, or perhaps the drill originates in another room, but they must respond to the drill. Their response may very well be different.
  • The drill must include the activation of the fire alarm system. This is a requirement. If the drill is conducted between 9:00 pm and 6:00 am, the audible notification devices (horns, bells, chimes) may be silenced.
  • The drill must include simulated conditions. This can be a pretend fire in a waste container or an electrical pretend fire. Some organizations use a revolving red light to simulate a fire condition.
  • At least 50% of the drills are unannounced. This means you cannot page “Code Red – This is a drill” during the drill, since that announces it is a drill.
  • Simulated patients must be moved to another smoke compartment during the drill. If relocating the simulated patient in the OR is not feasible due to the simulated surgery in progress, then alternative action must be taken to protect the patient.
  • Observers are needed to critique the response of the staff, the response of the fire alarm system, and the response of the building’s fire-safety features. The LSC and the Joint Commission standards do not say where you observe and how many observers you have, but logic dictates that you need to observe where the simulated fire is at, and in other compartments. How many other compartments? There is no direction on how many other compartments so you get to decide.
  • The fire drill critique must be documented, and the expectation is the summary of the drill is reported to the Safety Committee.

However, Since CMS adopted the 2012 edition of NFPA 99, they are now enforcing the new requirement for fire drills in OR surgery found in section 15.13.3.10.3 of NFPA 99-2012, which requires annual fire drills in operating rooms and surgical suite locations.

Locks on Operating Room Doors

Q: Our operating rooms were constructed with deadbolt locks on each surgical room. I’m told they did this to keep someone from entering the room during a case. Since this is most likely the path of egress I can’t see this being okay by the LSC. Your thoughts?

A: I would agree with you… But there are quite of few variables here. First of all, is the OR area a suite of rooms? If so, then the doors to the operating rooms do not have to latch, and a thumb-turn handle on the egress side to unlock a dead-bolt would be permitted since there is only one action to operate the door (see 7.2.1.5.10.2 of the 2012 Life Safety Code). But, if the operating rooms are not in a suite, then no, you would not be able to have dead-bolt locks because the doors would have to latch (since they open onto a corridor) and that would mean there would be two actions to operate the door: 1) To unlock the dead-bolt, and 2) Unlatch the latchset hardware.

Now section 7.2.1.5.10.6 of the 2012 Life Safety Code modified some of that and says existing doors are permitted to have two releasing operations to a room serving not more than 3 occupants, provided it does not require simultaneous operations to unlock the door. But… the typical operating room serves more than 3 occupants, so I don’t see that section working for you.

I would say it boils down to whether or not the OR is a suite of rooms. If yes, then the dead-bolt locks may stay if there is only one action to operate the door. If no, then you have to remove the dead-bolt locks.

Water-Mist Fire Extinguishers in the ORs

Q: Our facility recently installed water-mist fire extinguishers in all of our operating rooms, which is the sole fire suppressant. Is this acceptable?

A: It could be okay to have water-mist portable fire extinguishers in the operating rooms, provided there is a Class B:C fire extinguisher within 50 feet travel distance from inside the ORs.

The typical water-mist fire extinguisher is rated for Class A and Class C fires; both of which are possible in an operating room. But what about Class B fires? Most operating rooms are known to have flammable liquids, and a Class B fire extinguisher would be required. NFPA 10 says the travel distance to a Class B fire extinguisher is either 30 feet for low capacity extinguishers and low hazard areas, or 50 feet to moderate capacity extinguishers and low to moderate hazards. The OR could be rated as a low hazard area, but typically a Class 10-B CO2 extinguisher qualifies for a 50-foot travel distance and a Class 5-B CO2 extinguisher qualifies for the 30-foot travel distance.

But I would suggest that your Infection Control people weigh-in on this debate because the typical water-mist fire extinguisher consists of tap water, pressurized with compressed air. That is a recipe for a breeding-ground for germs. I’ve seen some hospitals use distilled water in their water-mist fire extinguishers and pressurize it with nitrogen, to discourage germ growth. But the IC folks should have a say in this because a water-mist fire extinguisher would be expected to be used on a patient who is on fire, in surgery with an open cavity.

Here is what I would suggest:

  • Remove the water-mist fire extinguishers from the operating rooms.
  • Install 10-lb Class 10-B:C CO2 portable fire extinguishers inside each OR. This will handle all Class B and Class C fires that may occur in the OR. Discharging a CO2 extinguisher in an operating room would not be detrimental to the patient.
  • Rely on the staff having sterile water in the operating field to extinguish any Class A fires that may occur. Sterile water dosed on a patient would not be detrimental to the patient.
  • Definitely remove all Class ABC dry chemical fire extinguishers from the surgery department, so they will not be accidentally used on a patient. Nearly the last thing you want is dry powder sprayed into an open cavity of a patient during surgery.

You say the water-mist fire extinguishers are the sole fire suppressant. Does the OR have water-based fire protection sprinklers? If not, why not? There have been some mistaken ideas that water drips from sprinklers and some surgeons ‘prohibit’ sprinklers in their ORs. While it is true that a defective sprinkler could drip water, it is extremely rare and unlikely. Nevertheless, a pre-action sprinkler system would be an acceptable answer as the sprinkler pipe over each OR would be dry.

OR Fire Drills

Q: We just had an accreditation survey and the surveyor cited us for not having a separate fire drill in the Operating Room Suite. I don’t see this in any code or standard.

A: You are correct in saying that there is no standard which requires a fire drill to be performed in the surgery department. However, there are circumstances where this would be expected, and a surveyor could cite you for not conducting a drill in the OR. Here are some situations that would lead a surveyor to believe a fire drill should be conducted in the operating rooms:

  • Surveyor preference. It is possible that the surveyor has a prejudice for fire drills in the Surgery department. If he/she failed to provide a reason why they cited this finding, then it may be presumed they just did so, because they think it should be done; not because it needs to be done. The surveyor needs to say why a fire drill is needed in the Surgery department.
  • Previous history. If there has been a historical event in your Surgery department (such as a fire during a surgical procedure), then it is a reasonable expectation by the surveyor that you address this issue with fire drills. However, if this is the case, the surveyor needs to state the reason why they are citing you for not conducting fire drills in the Surgery department.
  • Lack of documented response during fire drills. According to accreditation standards, staff must participate in fire drills. This does not mean that a fire drill must be conducted in every unit in the hospital, as staff on the 1st floor may participate in a drill conducted on the 4th floor, as long as the building’s fire alarm system was activated. If the source of the alarm was on the 4th floor, staff on the 1st floor are still expected to participate, by closing doors, and preparing to receive evacuated patients. In many hospitals the expectation is to suspend the start of surgeries during a fire alarm until the ‘all-clear’ signal is given. The way to document that all staff participate in fire drills is to have observers on select units and floors to document what the staff did. If you have no documentation that someone observed how the staff in Surgery responded to the alarm, then I can see where the surveyor may have a legitimate concern for a finding.

If in fact you do have documentation that observed the Surgery staff’s response during a fire drill, then that should qualify as participating in a drill.

Operating Room Entrance Doors

Q: Concerning latching hardware for a surgical suite, I could not locate any exceptions in the Life Safety Code to the positive latching requirements concerning operating room doors. From an infection control standpoint, the doctor having to handle a lever after scrubbing would not be desirable. Since the operating room is positive pressure, and the doors swing into the room, the positive pressure keeps the doors in a closed position full time. Are there waivers issued for these situations?

 A: Entrance doors to operating rooms that positively latch can have hardware devices that resemble ‘paddles’ and are easily actuated by elbows, hips or shoulders. The physicians and nurses do not have to touch the paddles with their hands, which may be considered sterile from scrubbing. The bigger question to consider in this scenario is do the entrance doors to the operating room actually have to positively latch? This can be easily answered by determining if the Surgical OR area is a suite of rooms or not. If the OR area is a suite, then the entrance doors to the operating rooms do not have to latch. However, if the OR area is NOT a suite, then the entrance doors to the operating rooms must latch since they are doors that open onto an exit corridor. The OR area is either a suite or it is a series of exit access corridors. The advantage of a suite is there are no requirements for corridors inside the suite because it is a room. Therefore, what looks like a corridor is actually a communicating space and the minimum widths pertaining to aisles in a communicating space (see section 7.3.4.1 of the 2000 LSC) are required to be maintained (28” for existing and 36” for new). That means the restrictions about storing items (such as medical equipment and non-combustible supplies) in the corridors no longer applies. Also since there are no corridors, there are no requirements for corridor doors, which means if there are doors to the inner-rooms (other than doors to exits or hazardous rooms), they do not have to latch. This is a huge advantage for those high-acuity areas such as ERs and ICUs where staff needs to have access to their patients quickly. As far as waivers are concerned, it would be very unlikely that the Centers for Medicare & Medicaid Services (CMS) would grant a waiver for a corridor door to an operating room that is required to latch. All waivers and equivalency requests must be submitted through your accreditation organization or state agency, who then submits them to the appropriate CMS regional office for approval. Only CMS is able to approve waivers or equivalency request, according to the recent proposed rule on the adoption of the 2012 edition of the LSC.

Operating Room Doors

Q: We just had an outside company update our SOC (Statement of Conditions) and even though we haven’t changed anything in 20 years he noted what he considered to be a deficiency.  The doors into the OR rooms do not have positively latching hardware even though they come off an egress hallway. Is there an allowance for usage vs. Life Safety Code? Latching all of the OR doors would become more of an infection control issue since staff would have to reach out and grab a door knob potentially infecting theirs hands instead of backing into the rooms. Is this something our AHJ would have discretion over? Unless there is some way to break it up the area is too big to be considered a suite.

A: You mentioned that the entrance doors to the operating rooms are from an egress hallway, and the Surgery department does not qualify as a suite-of-rooms since it is too large in square footage.  Therefore, the door to the operating rooms would have to positively latch, since they open onto the corridor.  But, you asked if there are “allowances” in the Life Safety Code that would allow these doors to continue to be non-latching. Yes, there are, but they are not always the best options to take. Here are my suggestions on how to resolve this problem. First, I would do whatever I could to make the OR area qualify as a suite-of-rooms. Work with your architect to design a way to create walls and doors to lower the total square footage to no more than 10,000 square feet. Secondly, consider requesting an equivalency from your authority having jurisdiction on a suite of rooms that is too large (see Q&A on over-sized suites of rooms, posted February 28, 2013). Thirdly, if the two suggestions above are not an option for you, then you MUST install positive latching hardware on the doors. This is not as bad of an option as you implied. I disagree that positive latching hardware would be an infection control issue, as there are numerous options in hardware designs that area available which are actuated by elbows and hips. Positive latching hardware is on thousands of operating room doors and there is no report or indication that it is an infection control issue.