Jun 01 2018

NFPA 99 Signs on Doors to Central Supply Systems

Category: BlogBKeyes @ 12:00 am
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Q: According to Joint Commission standard EC.02.05.09 EP4 it is requiring this sign:
“Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening.” They are referencing NFPA 99 2012-5.1.3.1.1–5.1.3.1.7. Am I understanding correctly that if I have Oxygen, Medical Gas and Nitrous in the Medical Gas Storage Room that this is the correct sign I need?

A: I think you have this twisted a bit. Joint Commission’s standard EC.02.05.09, EP 4 (2018 CAMH) does not reference NFPA 99-2012 5.1.3.1.1 to 5.1.3.1.7. The EP 3 (located above EP 4) does, but EP 4 does not reference any NFPA standard or sub-section of NFPA 99.

So… where did Joint Commission get the information for EP 4? From NFPA 99-2012, section 5.1.3.1.8. But according to NFPA 99-2012, 5.1.3.1, sub-section 5.1.3.1.8 applies only to Central Supply Systems. This sign that 5.1.3.1.8 requires (Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening) is only required for Central Supply Systems, such as gas manifold rooms. It is not required on doors to storage rooms on units that contain less than 3,000 cubic feet of oxidizing gases.

Also, NFPA 99-2012, section 5.1.3.1.9 says locations containing Central Supply Systems or cylinders containing only oxygen or medical air shall have their doors labeled: “Medical Gases: NO Smoking or Open Flame”. Since this is a sub-section of 5.1.3.1, this requirement still only applies to Central Supply System locations, such as gas manifold rooms.

But the way Joint Commission’s EC.02.05.09, EP 4 is written, it does not really limit the signs to just Central Supply Systems….

My advice is to contact the accreditor for clarification.

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May 25 2018

NFPA 99 Risk Assessment – PLEASE READ THIS

Category: BlogBKeyes @ 12:00 am
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Q: I need to do the NFPA 99 risk assessment of my hospital. I was told by one of my consultants that I have do this risk assessment from a room-by-room perspective, and he provided me a form from ASHE that lists this assessment by room-by-room. Is this true…? Do I have to do this assessment for each room?

A: No… that’s not correct. Yes, ASHE does have a form that does imply a room-by-room assessment is needed for the Chapter 4 risk assessment, but that’s not required by Chapter 4. What is required is an assessment of building systems based on a defined risk assessment procedure. Chapter 4 does not define the risk assessment procedure that you should use, but the Annex section does identify three risk assessments that they suggest, and the ASHE room-by-room assessment form is not included in these three suggestions. To be sure, you may use the ASHE form if you wish, but then you can use any risk assessment form that you want.

The core of the risk assessment is to determine what level or category the following building systems falls under, in the event of a total catastrophic failure of that system:

  • Gas & Vacuum Systems
  • Electrical Systems
  • HVAC Systems
  • Electrical Equipment
  • Gas Equipment

There are 4 levels or categories:

  • Category 1:    Systems in which failure is likely to cause major injury or death of patients or staff
  • Category 2:    Systems in which failure is likely to cause minor injury to patients or staff
  • Category 3:    Systems in which failure is not likely to cause injury to patients or staff
  • Category 4:    Systems in which failure would have no impact on patient care or staff

The process in the assessment is to determine the level of risk to the patient or staff if there is a catastrophic failure of that particular system. Another way of saying this is “Worst case scenario”.

As an example, let’s take the hospital’s electrical system: The risk assessment must assume a catastrophic failure of the entire system. The normal power system fails, and then the emergency power system from the generators fail. In other words, you have no power whatsoever in the building. Now, what is the level of risk to your patients? It will probably be Category 1, right?

You then do that type of catastrophic failure risk assessment for each of the above listed systems. If you want, you can break this down into different assessments of systems that are the same type. Such as HVAC systems: If the HVAC system fails in patient care areas, then that would be a certain high-level of risk to the patients. But if the HVAC system fails in the Administration wing, it would not be a risk to your patients, and it would be a low risk to your staff.

For hospitals, the expectation would be all of the above systems would be assessed as a Category 1 or Category 2. But for a medical building that only has physician offices and administrative support areas, the expectation is the above systems would be assessed as a Category 3 or Category 4. All healthcare facilities must be assessed for the risk level to patients and/or staff.

You have to document your assessment using a defined process. You can down-load a simple one-page risk assessment from my website and see if that meets your expectations.

The ironic thing is, the NFPA 99-2012 Technical Committee on Chapter 4 did not intend for this risk assessment to be conducted on existing systems. I talked with two members of that committee and they said the committee believed it was obvious the way it is written that this risk assessment is only required for new construction, since most (not all) of NFPA 99 is for new construction.

But CMS did not get that message and they require all of their state agencies and accreditation organizations to evaluate the risk assessment during all surveys. In other words; They fully expect all CMS certified healthcare organizations to have the Chapter 4 risk assessments completed by now.

In my opinion, this risk assessment does not require a lot of time to conduct. As I said, CMS expects all hospitals to have Category 1 or Category 2 systems. This is something you and your staff can do.

Just last week I received a call from a friend of mine who is a facility manager in the Midwest. He returned from a regional ASHE meeting where one of his fellow facility managers was recently surveyed by a leading accreditation organization (AO). The surveyor for the AO cited them for not doing their NFPA 99 risk assessment in accordance with the ASHE form, and do a room-by-room assessment. Please understand that this surveyor was incorrect to make that citation.

There is no NFPA requirement, no CMS requirement, and no AO requirement for healthcare organizations to do a room-by-room assessment to be in compliance with Chapter 4 of NFPA 99-2012. As mentioned above, you can use whatever risk assessment format you wish. The only requirement is the risk assessment must be documented and the surveyors will expect it to be reasonable (meaning all systems in a hospital are Category 1 or Category 2 systems).

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May 22 2018

Hospital-Grade Receptacle Testing

Category: BlogBKeyes @ 12:00 am
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Q: All of our receptacles in patient care rooms are hospital grade and therefore do not have to be tested annually, correct? What I don’t understand is section 6.3.4.1.2 of NFPA 99-2012, which states additional testing of hospital-grade receptacles in patient rooms shall be performed at intervals defined by document performance data. What is document performance data? How do I determine my testing intervals by document performance data?

A: You are correct: Hospital-grade receptacles are not required to be tested annually, but they are required to be tested at intervals determined by the healthcare facility. This is what the NFPA 99-2012 Handbook says about maintenance and testing of electrical receptacles under section 6.3.4.1 of NFPA 99-2012:

NFPA 99 prescribes no time between test intervals for hospital-grade receptacles. Hospital facility managers are permitted to determine appropriate test intervals for hospital-grade receptacles based on ‘documented performance data’. However, this paragraph requires that all non-hospital-grade receptacles within patient bed locations and anesthetizing locations must be tested at least every 12-months. This immediately raises the following question” “What is documented performance data?” There are two possible kinds of data that could meet this requirement. First, the manufacturer could provide data of this sort. Second, experiential data from other hospitals that have used similar devices and documented their failure rates could provide the kind of indication needed for appropriate testing intervals.

So, section 6.3.4.1.2 of NFPA 99-2012 does say additional testing of hospital-grade receptacles in patient care rooms shall be performed at intervals defined by the hospital using information that provides evidence that supports the testing interval decision. This information may come from the manufacturer, or it may come from your own experiences in testing these receptacles. According to NFPA 99-2012, you do not have to test hospital-grade receptacles annually that are located in patient rooms and anesthetizing locations, but you do have to determine what the testing frequency of these receptacles will be based ‘documented performance data’.

The testing requirements that you will need to do is found in NFPA 99-2012, section 6.3.3.2, and is summarized here:

  • The physical integrity of each receptacle shall be confirmed by visual inspection
  • The continuity of the grounding circuit in each electrical receptacle shall be verified
  • The correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed
  • The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less that 4 oz (115 g).

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Dec 04 2014

Medical Gas Shutoff Valves

Category: BlogBKeyes @ 6:00 am
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imagesZ7K8PIAPI was recently a bystander amongst a discussion of healthcare facility industry experts, debating the NFPA requirements concerning the accessibility of medical gas shutoff valves in healthcare institutions. The original question asked was where does it specifically state that a medical gas zone valve box cannot have a wheeled obstruction in front it of it? While it is intuitive to keep the area in front of the shutoff valves clear, the question was a good one, as it appears the NFPA codes and standards do not specifically address the requirement to keep it clear.

The discussion that ensued was informative, as various standards were referenced as to support the opinion of the presenter. For example; Joint Commission standard EC.02.05.09, EP 3 says the valves must be accessible. But TJC does not define what ‘accessible’ means. According to the online dictionary, accessible is a place which is able to be reached or entered. So, if a wheeled gurney is placed in front of a medical gas shutoff valve, is it still accessible, if staff can reach over the gurney and actuate the valve? Or, is the shutoff valve still accessible if the gurney can be moved so staff can reach the valves?

The only one who can answer that question is the authority who is enforcing that standard, which is The Joint Commission in this case, but the other accreditation organizations have similar standards and they make their own interpretations as well. According to most of those in the discussion, Joint Commission and the other accreditation organizations are writing up hospitals and ambulatory surgical centers that have anything placed in front of the medical gas shutoff valves.

Another individual referenced NFPA 99, 1999 edition, which governs medical gas systems for healthcare institutions. Section 4-3.1.2.3 (i) which requires manual shutoff valves in boxes to be installed where they are visible and accessible at all times; the boxes should not be installed behind normally open or normally closed doors, or otherwise hidden from plain view. This description would seem to support the concept that the definition of accessible could include a wheeled object to be placed in front of the valves as long as the valves were accessible. At the least, it doesn’t seem to prohibit that.

But yet another individual said take a look at NFPA 99 (1999 edition), section 4-2.1.2.3 (d) on zone valves. For sake of clarity, I will repeat it here word-for-word (bold emphasis is mine):

Station outlets shall not be supplied directly from a riser unless a manual shutoff valve located in the same story is installed between the riser and the outlet with a wall intervening between the valve and the outlet. This valve shall be readily operable from a standing position in the corridor on the same floor it serves. Each lateral branch line serving patient rooms shall be provided with a shutoff valve that controls the flow of medical gas to the patient rooms. Zone valves shall be arranged that shutting off the supply of gas to one zone will not affect the supply of medical gas to the rest of the system. A pressure gauge shall be provided downstream of each zone valve.

The above description is found under a section titled “Zone Valve”. The bolded section in the above description refers to the requirement of a manual shutoff valve that is located on the same story which is readily operable from a standing position in the corridor. That’s not necessarily the zone valve, but why isn’t this description also included in section 4-3.1.2.3 (i) which describes shutoff valves? The 2012 edition of NFPA 99 further elaborates on ‘Zone Valves’ and describes them in the same way that most people think of shutoff valves.

According to the online dictionary, the word ‘readily’ means without difficulty or delay; easily or quickly. So section 4-3.1.2.3 (d) of NFPA 99 (1999 edition) makes it pretty clear that the manual shutoff valve for the room outlets must be operated easily, and without delay. Parking a wheeled gurney in front of a medical gas shutoff valve could easily delay the operation of the valve; or at the minimum, it would provide a hindrance to the operation of the valve. Therefore, the wheeled gurney (or any other object) would not be permitted to be placed in front of the medical gas shutoff valves.

I think the accreditation organizations have got this issue correct. Anything that blocks access to a medical gas shutoff valves (whether it is called a shutoff valve or a zone valve) hinders the ‘readily operable’ capability of the medical gas valves, and would be a citable offense.

 

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Sep 19 2013

Medical Gas Shutoff Valves

Category: BlogBKeyes @ 5:00 am
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Medical Gas Shutoff Valves Blocked by Door Web 2

I received this picture recently from a good friend who works in a hospital, and is responsible for plumbing and power plant operation. He wanted to know if the medical gas shutoff valves which are located behind this door, are permitted since the valve box can be seen through the window in the door.

Apparently, the hospital installed new smoke compartment barrier doors in this area, and the previous doors were single-egress doors, which means both doors swung in the same direction. Well, according to section 4.6.7 of the Life Safety Code (2000 edition) when you make alterations and install new equipment, you must meet the conditions of the new occupancy chapter of the Life Safety Code, which in this case would be Chapter 18. Section 18. 3.7.5 requires new cross-corridor smoke compartment barrier doors to swing in opposite directions, or as commonly called, dual egress.

So, what happens in so many hospitals where the project team is not part of the facilities management team, some things get built or installed without the consultation and knowledge of those individuals who know the codes and standards the best. Now, I suspect my friend who sent me this picture knew the answer to the question before he sent it. At times, people need the assistance from consultants in order to emphasize the need for their own fellow employees to take action.

So, for those who may not know the answer… No. This condition is not acceptable.  According to section 4-3.1.2.3(i) of NFPA 99 (1999 edition), the shutoff valves must be installed where they are visible and accessible at all times. The [valve] boxes must not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

So what we see in the picture would likely be cited by a surveyor or inspector, especially since they can partially see the shutoff valve box through the window in the door. My friend says he will move the valve box, but I suspect that will cost quite a bit of funds, and a certain amount of medical gas interruption for the nursing unit. Not the best way to run projects.

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Oct 04 2012

Electrical Appliances Not Located in the Patient Care Vicinity

Category: BlogBKeyes @ 5:00 am
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I was recently asked how Joint Commission and other authorities look at  electrical items used by staff that do not come into contact with patients, such as refrigerators, fans, coffee pots and lamps.  Do hospitals have to remove all of these personal use appliances? The short and quick answer is No, but there are some things you need to be aware of.

When they do not have a direct standard which addresses the issue, Joint Commission will refer to NFPA 99 on the use and testing requirements for electrical equipment. They are permitted in the hospital, but they must be checked before they are placed into service. Take a look at section 7-5.2.2.1 of NFPA 99 (1999 edition) which says:

Patient Care Area: The leakage current for facility owned appliances (e.g. housekeeping or maintenance appliances) that are used in a patient care vicinity and are likely to contact the patient shall be measured. The leakage current shall be less than 500 microamperes. Tests shall be made with Switch A in Figure 7-5.1.3.5 in the open position for two-wire equipment that is not double-insulated. Household or office appliances not commonly equipped with grounding conductors in their power cords shall be permitted provided they are not located within the patient care vicinity. For example, electric typewriters, pencil sharpeners, and clocks at nurses’ stations, or electric clocks or TVs that are normally outside the patient care vicinity but might be in a patient’s room, shall not be required to have grounding conductors in their power cords.”

Note: Patient care vicinity is defined as a space for the examination and treatment of patients which extends 6 feet beyond the normal location of the bed, table, chair, treadmill, or other device that supports the patient during examination and treatment, and extends to 7 feet 6 inches above the floor.

As you may deduce, there is not a clear and simple standard that directly regulates electric appliances (such as lamps, refrigerators, fans and coffee pots) when they are not used in patient care vicinities. Here is what I believe Joint Commission and other authorities will expect from your organization in regards to electrical appliances that are away from the patient care vicinity:

1. Write into your Safety Management Plan (or it can be a separate policy referenced into your management plan) the organization’s plan of action concerning electrical devices that are not to be used within the patient care vicinity.

2. Upon initial installation (or before initial installation when the equipment is received at the hospital) conduct a current leakage test on the device, and document same. No further testing is required. If the device is removed and relocated, then a visual examination of the electrical cord needs to be conducted. No record of this visual examination is required.

3. Include language prohibiting the use of extension cords, power strips, adapters from 3-prong to 2-prong, and three-way adapters without the consent and permission of the Facilities department.

Having a policy on an issue when there is not a clear standard governing the issue, is an excellent way to demonstrate to the Joint Commission that you recognize the potential risk involved with the use of the device, and you have a plan to address it. If an electrical appliance shows up that doesn’t exactly fit into this policy, then conduct a risk assessment identifying all of the potential risks to patients, visitors and staff, and have it reviewed and approved by your safety committee.

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