Jun 29 2017

Evacuation to an Adjoining Building

Category: Evacuation,Questions and AnswersBKeyes @ 12:00 am

Q: Our fire plan says if there were ever a fire in our hospital, we would evacuate our patients horizontally to the other side of the smoke barrier. It then goes on to say that if further evacuation is ever required, patients would be taken down a stair located on the other side of the smoke barrier. Once in the stair, patients would be taken to at least 2 floors below the fire floor. Some floors in our hospital connect with another building. My question is: Instead of moving patients down the stairs in the hospital, can we move patients horizontally into another building separated by a 2 or 3 hour fire rating? People have different opinions on this. Some say it’s a good idea to move into a different building because you don’t want to move patients down the stairs, while others say you should always stay in the building and evacuate using the building’s stairs because once you’re in the stair, you’re in a 2-hour fire rated enclosure anyway. Does NFPA reference/requirement on this? If not, what would you recommend?

A: I’m not aware of any reference in the NFPA codes or standards that discusses the virtues of evacuating into another building, but I know it is done in many other hospital organizations. I think it is always best to continue to evacuate horizontally if you can, rather than vertically down a set of stairs. If you’ve ever been involved in a training event where simulated patients were used to evacuate down the stairs, you will quickly agree that should be the last resort.

For those individuals who say you should stay in your own building and evacuate down the stairs, I would respond saying why? What advantage is there? Yes, the stairwell does provide a certain level of safety from the fire (i.e. a 2-hour barrier), but so does the 2-hour occupancy separation (or 2-hour building separation) that an adjoining building offers. For those who say you should never take inpatients into a non-healthcare occupancy, I say poppycock! (My English grandfather used to use that word a lot). A fire event is an emergency and during an emergency you do what is best for the patient.

Change your policies if they say you don’t evacuate horizontally into an adjoining building, but rather down the stairs. You do what you have to do during an emergency. It is assumed that the evacuation of an inpatient into an adjoining building that is not healthcare occupancy would be for a short period of time. The patient may still require a certain level of care that may not be provided in an ambulatory healthcare occupancy or a business occupancy. In those cases, the patient should continue be evacuated to a location where they can be cared for.

And don’t forget the elevators. While elevators are not permitted as a required means of egress, they can be a secondary means of egress, provided the elevator is not actively involved in the fire. Find an elevator away from the fire (even if it is in an adjoining building) and use the elevator to evacuate patients.

Jun 12 2017

Evacuation Chairs in Stairwells

Category: Evacuation,Questions and Answers,StairwellsBKeyes @ 12:00 am

Q: I just got cited by the Joint Commission for having evacuation chairs at tops of our stairwells. The chairs were not causing any egress issues in my opinion, but the surveyor did not care that state fire marshal gave his blessing 8 years ago to have chairs at tops of stairwell and during the previous two Joint Commission surveys the chairs were not an issue. Your thoughts on this would be greatly appreciated.

A: First of all, it doesn’t matter what a state or local inspector or fire marshal says. Joint Commission and/or CMS does not have to comply with what a state or local authority says on an issue, and often does not care. All authorities having jurisdiction (AHJ) are equal, but separate. To have the permission or interpretation of one authority does not provide you with any leverage or influence with any other authority. Often times the authorities simply do not care what the other authorities say.

The Life Safety Code is not entirely clear on the subject of evacuation chairs mounted in stairwells. At one point (section of the 2012 Life Safety Code) the code says no space in the exit enclosure may be used for any purpose that has the potential to interfere with egress. One may conclude that if the evacuation chairs are mounted off to the side of the top landing where there is no possibility of egress interference, then you can mount an evacuation chair there. But the code does not specifically say that and it would have to be an interpretation by the authority to allow it.

But section also says an exit enclosure cannot be used for any purpose that has the potential to interfere with its use as an exit. According to the Annex section, the intent of this standard is the exit enclosure should be sterile with respect for fire safety hazards. The authorities can interpret this any way they want since the code is not clear.

Apparently, the Joint Commission (through the surveyor) is saying they will not allow it, and it is well within their right to say so. I have been in conferences where representatives from the Joint Commission engineering department say they do not allow stairwell evacuation chairs to be stored inside the stairwell.

Feb 17 2017

Evacuation Chairs Stored in Stairwells

Category: Evacuation,Questions and Answers,StairwellsBKeyes @ 12:00 am

Q: I understand it would be best to not place something affixed to the walls of the exit stairwell that protrudes in to the path of egress, which in turn, may interfere with egress. But we have two sets of stairwells, that in the middle of each floor, is a landing which has about a 7’ alcove going away from the path of egress on the landing, and the path of egress does not use this alcove.

So my question is, can we store evacuation chairs in these alcoves? I can understand affixing these items in the path of egress within the stairwell, can interfere with egress, but these alcoves are clearly out of the way and not in the path of egress.

A: To answer your question, let’s first take a look at section of the 2012 Life Safety Code (LSC), which says there shall be no enclosed, usable space within an exit enclosure, including under the stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

What this section appears to say is you may store your evacuation chairs in the alcove of your stairwell since the alcove is not part of the egress, and the stored evacuation chairs would not interfere with egress. But there are surveyors and AHJs that take a much more severe look at this issue, based on section of the 2012 LSC, which says an exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge.

Some AHJs take a very strong stand against anything being stored in the stairwells, but the Annex section of explains this requirement a bit further, and says the provision prohibits the use of exit enclosures for storage or for installation of equipment not necessary for safety. Occupancy is prohibited other than for egress, refuge, and access. The intent is that the exit enclosure essentially be ‘sterile’ with respect to fire safety hazards.

The above reference is in the Annex section of the LSC which means it is not part of the enforceable section of the code, but it is an explanatory section to help authorities understand the intent of the technical committee who wrote the code. Most AHJs follow what the Annex section says, although they do not have to. The Annex section for does prohibit storage in the stairwell that is “not necessary for safety”, but one could make the point that evacuation chairs are necessary for safety and therefore are permitted to be stored in the stairwell, as long as they do not interfere with egress.

The bottom line is it is apparent to me that the Life Safety Code does permit the storage of evacuation chairs in an exit stairwell, as long as the chairs are stored in such a way as to not interfere with egress. However, not all AHJs actually agree with this and some do cite hospitals if they have anything stored in the stairwells. If you want to pursue this and store the evacuation chairs in the alcove of your stairwells, I suggest you document these sections of the Life Safety Code and show them to any surveyor who questions the practice. It may prevent you from having a citation, or it may not.

May 18 2015

Evacuation Route Maps

Category: Evacuation,Maps,Questions and AnswersBKeyes @ 1:00 am

Q: Are evacuation route drawings required to be posted at nurse stations or anywhere else per Joint Commission or CMS requirements?

A: No. There is no Joint Commission standard or requirement and there is no CMS standard or requirement for evacuation route plans to be posted on units or in corridors. Although, having them in strategic locations are valuable teaching aids during routine fire drills. This is one of those great surveyor myths that seems to have been started decades ago by an misinterpretation by an official from CMS (or as it was called back then, HCFA). You may want to check with your local and state authorities to see if they have any requirements on this issue.

Mar 02 2015

Evacuation Chairs

Category: Evacuation,Questions and AnswersBKeyes @ 6:00 am

Q: Are stairway evacuation chairs required in all high rises, or business occupancies in general?

A: According to the Life Safety Code, there is no requirement to provide stairway evacuation chairs in any specific occupancy, hi-rise or otherwise. However, the Life Safety Code (as well as any of the Accreditation Organizations, such as Joint Commission, HFAP, and DNV) requires you to have a fire safety plan that includes plans for evacuation. If your organization chooses not to use stairway evacuation chairs to evacuate your patients, then you must have an alternative method to evacuate patients. Incidentally, the Life Safety Code does not restrict the storage of evacuation chairs inside a stairwell, as long as it does not interfere with egress. The only place that qualifies for ‘not interfering with egress’ is usually at the top of the typical stairwell. As always, please check with your state and local authorities to determine their regulations concerning evacuation chairs.

Dec 15 2014

Hotel Room Evacuation During Fire Alarm

Category: Evacuation,Fire Alarm,Hotel,Questions and AnswersBKeyes @ 6:00 am

Q: We own and operate a hotel on our hospital campus and are revamping our fire plan. Are we required to have all the hotel guests evacuate their rooms upon activation of the fire alarm? Also, we have a marked exit into a courtyard with a 6 foot high fence around it. The gate in the fence then leads to the public way. Must this gate remain unlocked for egress to the public way or can you have an assembly point inside the courtyard?

A: Section of the 2000 Life Safety Code states the fire safety information that is posted in the hotel room is sufficient for the guests to make their own decision as to whether or not they evacuate their rooms and/or building during a fire alarm. In an obvious fire alarm testing situation, I can see that is a legitimate situation where evacuation is not necessary. But other than that, appears to leave that decision up to the guests. However, it would seem logical to want everyone to evacuate whenever a fire alarm is activated.

In regards to the fence surrounding the courtyard, that presents other problems. Since you say it is a marked exit, then the exit discharge is required to extend to the public way. The public way is defined as a street, alley, or other similar parcel of land essentially open to the outside air, which is dedicated or otherwise permanently appropriated to the public for public use. A fenced-in area that has a locked gate does not seem to meet this definition of public way. In my opinion, the gate would have to remain unlocked. The gate would also have to be an obvious point of exit, or it would have to be marked with an illuminated exit sign, and the path of egress to the public way would need to be illuminated with emergency power. Even if you got a local authority having jurisdiction (AHJ) to allow the locked gate in the courtyard, that does not mean other AHJs would see it the same way.