Handrails

Q: According to the 2012 Life Safety Code, section 7.2.2.3.5, the distance between a handrail and adjoining wall should be 2¼-inches. Does this apply to just spaces in which NFPA requires handrails such as stair and ramps, or does it apply to corridors where a handrail is not specifically required by NFPA? If so, then in areas where NFPA does not require a handrail, but one is installed such as in a corridor, can the distance between the handrail and the wall just have to comply with ADA and the building code, which is 1½-inches?

A: Section 7.2.2.4.4.5 of the 2012 LSC does require new installation of handrails on stairs and ramps to be at least 2¼ inches from the wall. Since section 7.2.2.4.5 is a sub-section of 7.2.2 “Stairs”, this 2¼ inch requirement is limited to just stairs and ramps. It does not apply to handrails on corridors.

I do not see any restrictions on clearance between a handrail and the wall in corridors, other than the CMS limitation of 4-inches maximum projection into the corridor.

Strange Observations – Sprinkler Pipe Suspended From Ductwork

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

Some organizations fail to install sprinklers underneath the ductwork that is 48-inches wide or wider. This facility did not forget, but the sprinkler-fitter who installed this pipe for the sprinkler head attached it to the ductwork, which is not permitted.

The sprinkler pipe can only be suspended from the building itself (i.e. structural beams, joists, etc.), and not from anything else.

There is one exception to that rule… Sprinkler pipe may be suspended from a hanger that also supports ductwork, provided the hanger is designed to support the weight of the duct, the pipe, the water in the pipe, and an additional 250 lbs. (see NFPA 13-2010, 9.2.1.5). If you ever see sprinkler pipe suspended from the same hanger that supports ductwork, ask the installer to provide documentation that the hanger can support that weight.

Staff Sleep Rooms

Q: In regards to audio/visual strobes in staff sleeping rooms, is it required for them to hear the fire alarm system?

A: According to section 26.3.4.5.1 of the 2012 Life Safety Code, single-station smoke alarms are required to be installed in sleeping rooms for lodging or rooming house occupancies. A staff sleeping room in a hospital would have to qualify for the requirements of a lodging or rooming house occupancy, so a single station smoke alarm is required.

A single station smoke alarm has a built-in occupant notification device. But section 9.6.2.10.1.4 of the 2012 Life Safety Code says fire alarm system smoke detectors that comply with NFPA 72 and are arranged to function in the same manner as a single-station smoke alarm shall be permitted in lieu of smoke alarms. Even if you install a fire alarm system smoke detector in the staff sleeping room, section 9.6.2.10.1.4 would imply that some sort of occupant notification device is still required to awaken the staff member sleeping in that room.

But section 18.4.4 of the NFPA 72-2010, allows for the Private Mode installation for fire alarm system occupant notification devices, and hospitals typically are designed to this requirement. Section 18.4.4.1 requires the occupant notification device to have an audible sound level 10 dB above the average ambient sound level to be compliant, and in many cases, an occupant notification device located in the corridor outside of the staff sleeping room can achieve this requirement.

If you measure the dB level inside the staff sleeping room of the corridor-mounted fire alarm system occupant notification device, and it is 10 dB above the average ambient sound level in the staff sleeping room, then you should be good. But have those sound readings available to show the surveyor, as they will want to see some proof of compliance.

Fire Extinguishers

Q: At our hospital there is some question about which type of portable fire extinguisher should be installed in our operating rooms. We can’t find an actual requirement for this and would appreciate your opinion.

A: I don’t think you will find anything in the NFPA codes and standards that recommends a type of fire extinguisher to be used in an operating room. To be sure, section 9.7.4.1 of the 2012 LSC says portable fire extinguishers must be selected, installed, inspected, and maintained in accordance with NFPA 10.

Section 5.1 of NFPA 10-2010 says the selection of fire extinguishers for a given situation shall be determined by the following factors:

(1) Type of fire most likely to occur

(2) Size of fire most likely to occur

(3) Hazards in the area where the fire is most likely to occur

(4) Energized electrical equipment in the vicinity of the fire

(5) Ambient temperature conditions

So, what types of fires are likely to occur in an operating room? I would say Type A fires (fires involving combustibles like paper, plastic, cardboard, linen); and Type B fires (fires involving combustible and flammable liquids, like skin prep alcohol); and Type C fires (fires started by electrical means). I don’t believe Class D fires (combustible metals) and Class K fires (cooking oils) are very likely in an operating room. 🙂

So, you need portable fire extinguishers that will cover ABC fires, but the most common ABC extinguisher is a dry powder and is not suitable to be used in an operating room. So, you could use a CO2 type extinguisher which could handle BC fires, as the CO2 is a clean agent that would not do any residual harm to the patient. But what to do about Class A fires? Most surgical procedures have sterile water in a basin in the sterile field of the surgery. You can teach the staff to use the sterile water on any Class A fire involving the patient or nearby.

Keep in mind, there is no requirement that you have to have portable fire extinguishers in the operating room. All you need is to meet the maximum travel distance to get to a fire extinguisher. You could place a Class BC extinguisher out in the corridor outside the operating room, which would be fine as long as you do not exceed the travel distance to get to a Class B extinguisher, which is 35 feet for a 5-lb. unit and 50 feet for a 10-lb. unit.

Fire Extinguishers

Q: Do fire extinguishers that are placed in patient care areas of a hospital have to be placed in a wall cabinet, or can they hang from the wall?

A: NFPA 10-2010 does not require extinguishers to be mounted in a wall-cabinet. They are permitted to be mounted on a wall without the use of a cabinet. But be aware that CMS limits all wall projections into the corridor to be no more than 4 inches, which the average 10-lb. extinguisher would exceed.

Consider the Oval brand of fire extinguishers, as they project less than 4 inches.

Duct Detectors

Q: With regard to testing duct detectors in a hospital, I understand that on an annual basis the automatic shutdown of the AHU’s must be verified when duct detectors are activated. I am unclear if there is also an annual requirement to verify damper (pneumatic and/or electric type but excluding fused links) operation at the same time. Also, is there a requirement to test air differential on duct smoke detectors annually.

A: You don’t have to test the damper at the same time that you’re testing the duct detector or fan shut down and you do have to test duct detector air flow differential annually.

  • Per NFPA 72 (2010) testing frequency Table 14.4.5.18, emergency control functions that are interfaced with the fire alarm system must be tested annually.  The testing methods Table 14.4.2.2.23 states an emergency control  function must be tested at the same frequency (not necessarily at the same time) as the initiating device that controls.  So technically, the damper doesn’t have to be tested at the same time as the duct detector; just tested annually by operating or simulating the alarm activation (test switch).  I clarify that in case there’s a reason you don’t want to close the damper or shut down the fan the day you’re scheduled for testing the duct detector.  As long as it’s tested within 365 days of its last test, you’re good to go.  Also, you have to observe the damper blades fully close.  It’s not enough to listen to the actuator operate, so you may want to pass that on to the testing team and ensure there’s a space on your testing form to confirm that the damper closure was visually confirmed.
  • Table 14.4.2.2.14(g)(6) covers duct detector testing methods.  It mandates not only testing smoke entry into the chamber and sensor sensitivity testing, but also air flow testing across the sensor.  The manufacturer should have an acceptable method in their installation manual, but the usual method is to use a manometer.  I don’t know of any manufacturer that wouldn’t use this method.  This is a new requirement with the implementation of NFPA 101 (2012) & NFPA 72 (2010) and your CMS enforcement agency will be looking for it on your testing paperwork, so if you’re using a 3rd party testing firm, ensure they’re employing this method as most won’t unless you hold their feet to the fire.

[NOTE: Gene Rowe from Affiliated Fire Systems contributed to this reply.]

Emergency Power Generators

Q: I am a consultant and I visited an ASC that had a natural gas generator housed indoors, located in the basement of the facility. The ATS switch was located in the same room as the generator. I am not used to seeing generators located inside of the building. Is the ATS allowed to be in the same room? Also, there was no emergency battery backup light at the location of the generator and there was no emergency stop button located anywhere in or outside of the facility. Isn’t this required?

A: The fact that the generator is located inside the building may be acceptable, depending when the generator was installed. NFPA 110-2010, section 7.2.1 says the generator shall be installed in a separate room and emergency power supply system equipment shall be permitted to be installed in this room. So, this allows the generator to be installed inside the building in a room, and this allows the ATS to be mounted in the same room.

According to section 7.2.1.1 the room must be separated from the rest of the building by 2-hour fire rated barriers, or the generator may be located outdoors. So, when you see generators mounted inside in a room, check the entrance door (if the door connects the room to the rest of the building) rating as it must be 90-minute fire rated, and the walls must be 2-hour fire rated without any unsealed penetrations.

According to section 7.2.1.2 nothing else, other than what has been described, may be permitted in this room. So the room cannot be used to store ladders, equipment, supplies, etc.

According to section 7.2.3, the room housing the generator must be designed and located to minimize the damage from flooding, caused by fire-fighter flooding; sewer backup; natural disaster. So, locating a generator in a basement does not seem to fit this requirement. This requirement was also found in the 1999 edition of NFPA 110, which was required to be complied with by CMS since March 11, 2003. So, if this generator was installed since March 11, 2003, I would say it is subject to a finding by a surveyor for not locating the generator in an area that would not be affected by flooding.

According to section 7.3.1, the generator equipment location must be provided with a battery-powered emergency lighting. So, if there is no battery powered emergency lighting unit, then that is a potential finding by a surveyor.

According to section 5.6.5.6 the generator must have a remote manual stop station located outside the room that houses the generator, and the remote manual stop station needs to be labeled. So, again, if there is no remote stop switch, then that is another potential finding by a surveyor.

Separation Between Hospital and Parking Structure

Q: We have a three-story parking structure attached to a hospital. The top floor of the parking structure is not covered and is open to the atmosphere. Is the exterior wall of the hospital adjacent to the top floor of the parking structure required to be fire-rated? Our original drawings show the wall as not rated.

A: Yes… I would say so. According to section 3.3.188.15 of the 2012 LSC, a parking garage would be considered a Storage Occupancy, and since this is contiguous to the hospital (which is a healthcare occupancy) section 19.1.3.3 (2) would require that you need a 2-hour fire-rated barrier separating the healthcare occupancy from the storage occupancy.

Technically speaking, the entire parking garage is open to the atmosphere, so the only difference between the top deck of the parking garage and the lower decks is there is no roof on the top deck. The top deck is still a storage occupancy just like the lower decks. The LSC does not allow any exceptions to not provide a 2-hour fire rated barrier between the healthcare occupancy and any other occupancy just because it does not have a roof.

Strange Observations – That’s a Huge Step

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

The maximum rise in a existing construction step is 8-inches. The step in the picture to get into and out of this electrical room is about 20-inches.

There is nothing in the Life Safety Code that excludes mechanical rooms, or electrical rooms from having to comply with the requirements for a maximum rise in the step.

In this situation, it was going to be difficult to install a set of steps because this opening to the electrical room is directly off of the drive to the receiving dock.

Fire Alarm Notification Devices in the OR

Q: Can you explain the fire alarm notification appliance location requirements as it pertains to the operating room? I seem to recall that there’s no requirement to have them in an operating room and, in fact, that it is generally more desirable to NOT have them since they may act as a distraction to the surgical team members. We are a two-hospital system with one of the hospitals having strobe only devices in each operating room and the other hospital having no A/V devices in their operating rooms.

A: Since hospitals are a patient relocation or partial evacuation facility, the private mode of alarm notification is allowed to help avoid a panic situation.  In private mode, the intent of notification (speakers, chimes, strobes, etc.) is to alert personnel responsible for taking action when the fire alarm system activates.  In other words, only key, responding personnel need to hear or see the audio/visual device or receive notification that an alarm has activated (corridors, nurse stations, engineering & back of the house areas, etc.).

These personnel aren’t normally found in operating rooms so there is no requirement to have notification devices in those areas. Even though we all know that surgeon distraction is a very good reason to not have them in operating rooms, NFPA 101 Life Safety Code developers try to stay away from potentially subjective exceptions when they can. Private mode notification is allowed so they don’t need to make a specific exception in this case.

However, there is an exception provided for critical care areas like NICU to use just visual devices. The reason for the difference between your two hospitals is probably that designers often forget or are unaware of private mode notification as an option for these types of facilities.  99% of the time they apply public mode notification that you see in most buildings.  Additionally, they have to consider ADA requirements and for some, it’s just too much time & effort to apply exceptions, so they just paint with a broad brush.

No one minds at the time so it goes forward.  If you’d like to eliminate strobes in the operating rooms, run it by the local fire department’s fire prevention officer, citing your concerns and using private mode notification as justification.  If he’s OK with it, you’ll need to update your system drawings and ensure the wiring is reconfigured correctly, so there’s some expense to doing it. [NOTE: Gene Rowe from Affiliated Fire Systems contributed to this reply.]

Signage Inside a Stairwell

Q: Can signage, other than that specifically required for inside a fire exit stairwell according to the LSC, be placed inside a fire exit stairwell?

A: Technically… no. According to section 7.1.3.2.3 of the 2012 LSC, it says the 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. The Annex section of A.7.1.3.2.3 says the intent is the exit enclosure essentially be ‘sterile’ with respect to safety hazards.

But, it probably depends on the signage that you want to install in the exit enclosure. If the signage is truly tight to the wall surface and cannot interfere with exiting, then most surveyors would not say anything. But if the signage was in the same style as a hanging framed picture, then that would likely be cited, since it could interfere with exiting when someone brushed their shoulder against the framed picture and it falls off the wall and becomes a trip hazard, or if it was tight to the wall, the projection of the frame could be an interference as well.

But, the Annex section says the stairwell should be sterile… so a technical interpretation could say nothing can be in the stairwell. I have seen surveyors cite organizations for painted-on signs inside stairwell walls because it would cause people to stop and read them, which, in the opinion of the surveyor, would cause a back-up of people egressing and in turn would interfere with the use of the stairwell. That sounds like an extreme interpretation, but one that the surveyor is permitted to make.

Air Pressure Requirements for OR Suite

Q: I have a small 28 bed hospital with one OR suite. Within the OR suite are sterile rooms, a soiled room, and of course the Operating Room, etc. We are rebalancing the air flows for the entire floor which is all health care occupancy. I am aware that the rooms mentioned above, all have air pressure relationship requirements to adjacent areas per the Guidelines for Design & Construction of Hospitals and ASHRAE 170. However, some are questioning the need to have a positive air pressure relationship between the OR suite and other areas. That is, they measure the pressure from the OR suite door to other side which is the in-patient corridor. Is there any pressure relationship requirement in this location?

A: None that I’m aware of. Since surgery departments may or may not be suites, the ASHRAE 170 ventilation Table 7-1 in the FGI Guidelines does not address that. You are correct that the actual operating room has to have a positive air pressure relationship to its surrounding areas. But I am not aware of any ventilation air-pressure requirement for the Surgery suite as measured at the suite entrance door.

Strange Observations – Monitor Leads in the OR

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

When I consult at a hospital or an ambulatory surgical center, I always gown-up and take a tour of the operating rooms… the vacant operating rooms, of course. I have no desire to enter an OR that has an active case, nor would I be allowed to enter.

This picture is of an operating room table that I was told was waiting for the patient to arrive. Can you see what is laying on the floor…? Those are leads to the medical equipment to monitor the patient.

While this is not a Life Safety Code issue, it is a serious Infection Control issue. You cannot have monitor leads lying on the floor that will be used on a patient. Show this to your Infection Control specialist at your facility, and ask them what they think.

Hazardous Rooms

Q: When dividing hazardous areas (particularly storage rooms exceeding 100 square feet), if there are several rooms in one area, is the one-hour fire rating allowed to surround the perimeter of all the rooms or does each room require a separate fire-rating?

A: There is no Life Safety Code requirement that would prohibit you from ‘grouping’ your multiple hazardous rooms together, into one large hazardous room, even though the multiple rooms are separated by non-rated barriers. So, yes, you can have the 1-hour fire rated barrier go around the outer perimeter of all the rooms and everything inside the 1-hour fire rated barrier would be considered a hazardous area.

GFCI Receptacles on Ice Machines

Q: We had our Joint Commission inspection today and they cited us for water coolers and ice machines not being plugged into GFCI (ground-fault circuit interrupter) receptacles. One of our buildings was built in 1972 and the other was 2008. They cited NFPA 99-2012 Chapters 6 and 9, under EC 02.05.05 EP 8. Do you believe that was a correct finding? Thanks

A: Yes… that is a legitimate finding.

NFPA 99-2012, section 6.3.2.1 says the electrical installation must be in accordance with NFPA 70 National Electrical Code. Article 210.8(B) of NFPA 70-2011 says ground-fault circuit-interruption for personnel protection shall be provided as required in 210.8(A) through (C). The ground-fault circuit-interrupter shall be installed in a readily accessible location.

Sub-section (B) “Other Than Dwelling Units” says all 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel:

(1) Bathrooms

(2) Kitchens

(3) Rooftops

(4) Outdoors

(5) Sinks — where receptacles are installed within 6 ft of the outside edge of the sink.

(6) Indoor wet locations

(7) Locker rooms with associated showering facilities

(8) Garages, service bays, and similar areas where electrical diagnostic equipment, electrical hand tools, or portable lighting equipment are to be used

So, item #6 ‘wet locations’ is the kicker on this issue. The AHJs are now interpreting anything that holds water to be a wet location, and therefore must have a GFCI receptacle. Another issue that you need to be aware of, is all GFCI receptacles need to be tested monthly. Ouch. More labor and documentation.

I don’t see where NFPA 99-2012 Chapter 9 (HVAC) applies in this issue, but it is a legitimate finding through chapter 6.