Aug 04 2014

Operating Room Entrance Doors

Category: Doors,Operating Room,Questions and AnswersBKeyes @ 6:00 am
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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.