Aug 11 2017

Blood Draw in Behavioral Health Corridor

Category: Behavioal Health,Questions and AnswersBKeyes @ 12:00 am
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Q: I have a behavioral health unit where the lab technicians have placed a chair in the corridor to draw blood samples from the patients. This chair is left in the corridor at all times, and the corridor is 8 feet wide. Is this a violation and do I need to maintain 8 feet clear width in this corridor?

A: Yes… I believe it is a problem, but not for the reasons you imply.

Section 18.2.3.5 of the 2012 LSC says corridors in psychiatric hospitals are required to have unobstructed clear width of 6 feet; not the traditional 8 feet clear width required in acute care hospitals. So, a chair placed in an 8 foot wide corridor in a psychiatric unit would likely not obstruct the required clear width of 6 feet. However, take a look at section 19.3.6.1. This section sates that corridors must be separated from all other areas of the hospital with partitions. Now, there are 9 exceptions where corridors are not required to be separated from certain areas of the hospital, but none of these exceptions allow areas used for patient sleeping rooms, treatment rooms or hazardous spaces to be open to the corridor.

The question here is; what constitutes a ‘patient treatment room’? Does a chair that is legally placed in the corridor for patient blood draw constitute a patient treatment room or space? Maybe yes, and maybe no. Being an engineer, I cannot make that decision. I suggest you have your clinical staff perform a risk assessment and review the procedures that are being done at this location to determine if it meets the qualifications for ‘patient treatment’. If the results of the risk assessment state that blood draw is not ‘patient treatment’ activities, then have them take the results of that risk assessment to the safety committee and the patient safety committee (if they are not one and the same) and have those committees review and approve the results.

If a surveyor challenges you that the blood draw constitutes ‘patient treatment’ activities open to a corridor, then present the risk assessment. While this is not a guarantee that the surveyor will accept the results of the risk assessment, it will demonstrate to the surveyor that you are aware of this issue and conducted an evaluation and determined it is not ‘patient treatment’ activities.