Strange Observations – Part 38

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

This hospital wanted to ‘fence off’ access to the MRI when it was not staffed. Apparently, they did not have a side-hinged swinging door assembly available, so they went with this removable gate.

The problem is, the gate is not side-hinged, and swinging and on top of that they put a padlock on the gate so anyone left in the room would be locked in.

Their reply was, they would ensure that no one is in the MRI area when they set up the gate. Sorry, but the LSC does not allow for that. The gate had to go.

Means of Egress Illumination

Q: We have a chapel/activity room that is used for bingo and worship services. Can you please tell me what the minimum illumination of the walking surface in foot-candles is required for this area?

A: Section 7.8.1 of the 2012 Life Safety Code discusses the requirements for the illumination of the means of egress. Keep in mind that the means of egress includes aisles and is not limited to just corridors. Therefore, the aisles inside the chapel/activity room would be required to meet the minimum illumination requirements. Normally, the minimum illumination requirement at the floor level (other than stairwells) is 1-foot candle according to section 7.8.1.3 (2), but a chapel/activity room would qualify as an assembly occupancy and the LSC allows less lighting levels of 0.2-foot candle during periods of performances or projections involving direct light. But 1-foot candle is not very much illumination and is about the brightness of a lit match. So, maintaining the minimum illumination requirements in the means of egress is achievable. Check with other governmental regulations to see if there are greater requirements for illumination of the means of egress. I’ve been told that OSHA requires a minimum of 5-foot candles of illumination for the means of egress.

Exiting Through a Shell Space

Q: Where in the ambulatory health care occupancy chapter of the Life Safety Code does it permit to have a means of egress from an ASC or a suite within the ASC be through a shell space or machine room? Is this allowed assuming that the proper signage and emergency lights are in place.

A: No… The path of egress cannot extend from a corridor into a room to get to an exit. Section 7.5.1.2 of the 2012 Life Safety Code does not allow this. Also, section 7.5.1.6 says exiting is not permitted through a hazardous room. So, if the shell space is used for storage then you cannot have a path of egress through the shell space. In ambulatory health care occupancies, any room used for storage is considered a hazardous room.

You cannot exit from a suite directly to another room. All required exits from a suite must lead to an exit access corridor, or to a horizontal exit, or to an exit stairwell, or to a direct exit.

Now, if you constructed an exit access corridor in the shell space to separate the stored items from the corridor, then that would be acceptable.

Path of Egress Through a Construction Area

Q: Are there any problems with maintaining an emergency exit for a hospital OR area that travels through an adjacent construction project? Also, can these doors be taped or sealed with a tape/barrier to limit construction dust?

A: In regards to your first question, what would your infection control practitioner say about exiting OR patients (who could possibly have open incisions) into and through a construction area? I’m sure that the IC person would have a fit about that. No… you can’t exit OR patients into and through a construction area. A construction area is typically a dirty, hazardous area depending on the level of demolition and construction. Section 7.5.1.6 of the 2012 Life Safety Code does not permit exiting through a hazardous area. Taping the seams and jamb of a door to prevent dust and dirt contamination would be a good approach to prevent dust and dirt from transferring from the construction to the clean side, but you can’t tape a door closed if the Exit signs tell you that is the path of egress.

You have to close the path of egress if the path is under construction. That is what alternative life safety measures are for (aka Interim life Safety Measures, or ILSM). It is okay to close one path of egress for the needs of construction as long as you conduct an assessment to evaluate what ILSMs are to be implemented. Then you follow what your ILSM policy says regarding closed (or obstructed) exits.

But you can’t tape a door shut that is in the path of egress and expect staff to use that door in the event of an emergency. And you need to come up with alternative measures to compensate for closing that path of egress. It is my observation that project people are not all that familiar with the ILSM method. It’s okay to close an exit if you have to remodel that exit. That’s why the LSC has a standard on ILSM. Most project people don’t know this and they try to maintain what they think has to be: two forms of exiting.

Required Exit from OR

Q: Can a sterile supply corridor that feeds the back of Surgical OR’s have a corridor of less than 8′ if the patient access is from the front of the OR? This front patient access provides the required exit access for inpatients to two exits.

A: Maybe. It all depends on whether or not the sterile supply corridor that feeds the back of the Surgical ORs could in any way be considered a path of egress for the inpatients receiving treatment in the OR. Is this path marked with ‘Exit’ signs? That is usually a dead-giveaway since it marks the path of egress through the sterile corridor as a means of egress for the occupants of the ORs. But, that is not the only indication. Even if the path is not marked with an ‘Exit’ sign, it could still be considered a required path of egress from the ORs. You mentioned that the front patient access provides the required exit access for inpatients to two exits. If that is true (and I have no reason to doubt you), then that may possibly make the sterile corridor to NOT be a required means of egress, and then it would not have to comply with section 18.2.3.3 (2000 edition) for 8 foot corridor widths for new construction. For existing construction, section 19.2.3.3 says 4 foot width is required, but if the corridor is already constructed to a width greater than 4 feet, then you must maintain to corridor to 8 feet of width if you make any alterations or renovations. Parking equipment in a corridor would be considered an alteration.

Before you make any changes to your facility, you need to discuss this issue with the architect who designed the egress routes from the ORs, if that person is still available. It is important that any change in function be reviewed by the proper individuals, which may also include your local or state authorities.