Electric Blankets

Q: Are electric blankets permitted to be used by patients in long term care facilities? I cannot find any references to electric blankets in any NFPA codes or standard.

A: Technically, you are correct: There is no specific NFPA code or standard that prohibits the use of electric blankets in healthcare. However, there are significant risks to the patient and staff if you do use them, and before you allow the use of electric blankets, you need to conduct a risk assessment. At a minimum, the risk assessment needs to address to following issues:

  • Could the heat generated from the blanket cause epidermal damage to the patient?
  • Could the electrical portion of the blanket become damaged due to abuse or spillage, and cause harm to the patient?
  • Could the electrical cord become damaged (frayed) by other wheeled equipment rolling on top of the cord?
  • Could the electrical cord become a tripping hazard to the patient or staff?
  • Could the patient accidentally set the temperature control too high and cause damage to their body?
  • How will the electric blankets be maintained and inspected, and who will perform this task?

Another issue that you need to address… Why do you want to use electric blankets? Is the patient room too cool for the patient’s comfort level? There are minimum temperature levels that the organization must meet. If a surveyor observes the use of electric blankets, they have the right to investigate to determine if you did a risk assessment that addresses all of the above issues, and more. They have the right to review your risk assessment and they have the right to disagree with the conclusions in the risk assessment. In other words, no matter how you justify their use, a surveyor can still cite you for an unsafe environment for using electric blankets if they want. My advice: Stay away from electric blankets, and do not allow them. They become more problems than they are worth. Check with your state and local authorities to determine if they have regulations that would prohibit their use.

Tamper Resistant Electrical Receptacles

images[5]Every surveyor has his/her own specialty that they like to look for during a survey. I know of one surveyor that writes up every hospital he surveys if the fire alarm panel is not marked with the electrical panel number and circuit that feeds the power to the fire alarm system. It’s a requirement, but he’s the only surveyor that I know who is writing it.

Another surveyor that I know is very astute on construction type to the point where he wrote up a hospital for having combustible siding on the exterior of the building. The hospital was 20 years old and the plywood siding was original. They were upset because for two decades the siding was never an issue, then all of a sudden ‘Boom’; it’s a problem. The hospital contacted the architect who originally designed the hospital, and he wrote a thundering letter of protest. That one I checked with NFPA and it turns out the surveyor was correct. The hospital will have to remove the combustible siding or submit an equivalency or a waiver request.

When I surveyed for The Joint Commission, I remember paying special attention to how fire dampers were installed at the hospitals I surveyed. I did this because the hospital where I worked got cited for improperly installed fire dampers by the state agency conducting a validation survey on behalf of CMS. I learned the hard way on the proper method of installing fire dampers, and used that newly gained knowledge when I surveyed.

Which leads me to the issue concerning tamper resistant electrical outlets. I don’t think you will see any specific standard in a Joint Commission, HFAP or DNV, manual (or in a CMS CoP for that matter) on tamper resistant electrical outlets, but this issue is being observed on more and more survey reports. Apparently, some surveyors have a strong background in the National Electric Code (NFPA 70) and uses that knowledge during surveys.

If you are not already doing so, please be checking the electrical receptacles in pediatric areas to be sure they are the tamper resistant type. Section 19.5.1 of the 2000 Life Safety Code requires compliance with section 9.1, and section 9.1.2 requires compliance with NFPA 70 National Electric Code (1999 edition). Article 517-18(c) of NFPA 70 says the receptacles rated for 15 or 20 amps, 125 volts, intended to supply patient care areas of pediatric wards, rooms, or areas in healthcare facilities, shall be listed tamper resistant or shall employ a listed tamper resistant cover.

 The areas where tamper resistant receptacles are required are areas where children are likely to found; which include areas outside of a pediatric unit such as the cafeteria, main lobby, waiting rooms, and play areas. The tamper resistant receptacles would not be required in adult patient rooms, corridors, physician consultation rooms, etc., as these areas, even if children are present, would have supervising adults present.

It is not wrong, or unethical for a surveyor to cite an organization on an issue just because he/she has special knowledge about that issue. After all; the hospital is required to comply with that issue, right? What’s frustrating is there usually is no warning that some surveyors are looking for a particular issue and it surprises facility managers when it happens. No one likes those kinds of surprises.

CMS Issues Categorical Waiver on Power Strips

12-120-878-TS[1]CMS issued a new S&C memo 14-46 in late September that made allowances for healthcare organizations to utilize power strips in patient care areas.

CMS has determined that the 2000 edition of the Life Safety Code contains provisions on the use of power strips in health care facilities that may result in unreasonable hardship for providers or suppliers. Further, CMS says an adequate alternative level of protection may be achieved by compliance with the 2012 edition of the Life Safety Code, which has extended allowances on the use of power strips in patient care areas.

CMS has determined that the 1999 edition of NFPA 99 Standard for Health Care Facilities, section 3-3.2.1.2 (d)(2) which requires a sufficient number of receptacles located so as to avoid the need for extension cords or multiple outlet adapters, is outmoded and unduly burdensome. NFPA 99 is referenced in part by the Life Safety Code. Power strips are also known as multiple outlet adapters, multiple-plug adapters, and relocatable power taps.

CMS says by contrast, the 2012 edition of NFPA 99 has extended allowances for use of power strips in ‘patient care rooms’, which replaces the term ‘patient care areas’.

The requirement in the 1999 edition of NFPA 99 for sufficient receptacles to be located in all patient care areas as to avoid the need for power strips has been removed in the 2012 edition. In place, the 2012 edition has increased the minimum number of receptacles in patient care rooms for new construction.

Effective immediately, CMS is permitting a categorical waiver to allow for the use of power strips in existing and new health care facility patient care areas/rooms, if the provider/supplier complies with all applicable 2012 NFPA 99 power strip requirements and with all other 1999 NFPA 99 and 2000 Life Safety Code electrical system and equipment provisions. NOTE: This applies to patient care rooms in all occupancies; not just healthcare occupancy. So does apply to patient care rooms in business occupancies as well as ambulatory care occupancies.

A patient care room is defined as any room in a health care facility wherein patients are intended to be examined or treated. This definition appears to include operating rooms and procedure rooms as well and is not limited to just healthcare occupancies.

The CMS S&C memo 14-46 describes basic requirements that health care facilities must comply with in order to use the new categorical waiver.

  • Patient bed locations in new health care facilities, or in existing facilities that undergo renovation or a change in occupancy, shall be provided with the minimum number of receptacles as required by section 6.3.2.2.6.2 of the 2012 NFPA 99.
  • Power strips may be used in a patient care vicinity to power rack-mounted, table-mounted, pedestal-mounted or cart-mounted patient care related electrical equipment assemblies, provided all of the conditions are met in section 10.2.3.6. They do not have to be an integral component of manufacturer tested equipment.
  • Power strips may not be used in a patient care vicinity to power non-patient care-related electrical equipment, such as personal electronics.
  • Power strips may be used outside of the patient care vicinity for both patient care-related equipment and non-patient care-related equipment.
  • Power strips providing power to patient care-related electrical equipment must be Special Purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL 60601-1.
  • Power strips providing power to non-patient care-related electrical equipment must be Relocatable Power taps (RPT) listed as UL 1363.

The categorical waiver is available to all health care providers and suppliers and need only to document their decision to use the waiver, stating that they comply with all of the requirements to do so. This document must be provided to the surveyor team at the entrance conference. Organizations wishing to use the categorical waiver need not apply for them or wait until they are cited to use them.

To review the CMS S&C 14-46 memo, follow this link:  http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-46.pdf

Storage in Electrical Rooms

Q: Can cardboard boxes be stored in an electrical room that is over 50 square feet, fully sprinklered, and has only dry transformers under 112 1/2 kVA?

 A: Yes, only if the room qualifies as a hazardous room under sections 18.3.2.1 or 19.3.2.1 of the 2000 edition of the Life Safety Code, depending if the room is considered new construction or existing conditions. With the exception of NFPA 1 (2012 edition) NFPA codes and standards do not prevent storage in electrical rooms as long as it does not obstruct access to the electrical equipment. Since NFPA 1 is NOT a referenced standard by the Life Safety Code, the restrictions found in that standard does not apply.  You must maintain at least 36 inches clearance in front of all electrical panels, and at least 30 inches clearance to the side of electrical panels. Now, other authorities having jurisdiction may have their own rules and interpretation, so I would suggest you check with your accreditation organization, state and local authorities to see if they have any issues with that.

Relocatable Power Taps (Power Strips)

12-120-878-TS[1]There has been a lot of discussion about power strips (or relcoatable power taps, as some authorities call them) lately, and most of it is not to our advantage. None of the discussion is actually news to us, it’s just a re-hash of existing positions.

During the recent NFPA Annual Conference in Las Vegas earlier this month, George Mills, the Director of Engineering for The Joint Commission said he approached the NFPA Healthcare Interpretation Task Force (HITF) back in 2007 and asked them to make a ruling on whether power strips are acceptable for use in patient care areas. George said after much discussion, the HITF did not come to a consensus, and therefore no interpretation was issued.

Since then, The Joint Commission surveyors have been allowing power strips in patient care areas, and some surveyors even required the devices to be UL listed for the application. Then, earlier this year, the leadership at The Joint Commission asked George what the accreditor’s official position was on the use of power strips, so he decided to contact the CMS home office in Baltimore to see what they allow.

George reported at the May AAMI Annual Conference in Philadelphia that CMS is taking the hard line of saying power strips (relocatable power taps) are not to be used in anesthesia areas and on medical equipment. This is based on NFPA 99 (1999 edition), section 7-5.1.2.5 which only allows relocatable power taps provided they are an integral part of the equipment assembly and permanently attached; and the sum of the ampacity of all appliances connected to the relocatable power tap shall not exceed 75% of the ampacity of the relocatable power tap. A regular program to verify the integrity of the above permanently attached relocatable power taps is required.

This piece of information was picked up by a lot of different healthcare news outlets, blogs and online notification services (including yours truly) and re-distributed to the point where CMS had to make an unofficial email announcement to their deemed accredited organizations (and presumably to their state agencies) that in fact no new issuance of a policy or an announcement was made concerning power strips, and they referred to NFPA 99 as their standard. Now ASHE has made an announcement acknowledging CMS’ position, and to say they are working to convince CMS to consider issuing a categorical waiver to allow the immediate use of NFPA 99 2012, which seems to have a more user friendly approach to power strips.

But, the bottom line is The Joint Commission (and the other accreditors) do not have any option but to follow this difficult interpretation of the standard as dictated by CMS. George Mills unofficially said they will enforce no power strips in patient care areas, and no power strips on medical equipment, unless it meets the requirement of NFPA 99 7-5.1.2.5 and it is integrated with the medical equipment, and this is all regardless of the UL listing. So power strips like UL 1363A which are listed for use in anesthetizing locations would not be acceptable to the accreditors.

For the record, the HITF wrestled with the issue of power strips once more this year in Las Vegas but again did not arrive at a conclusive interpretation. Chad Beebe representing ASHE said he wants to take this issue to CMS to attempt them to change their minds on the rigid interpretation.  I guess you need to stay tuned to see what transpires next…

IT Closets

Q: Are there any requirements to firestop penetrations in Information Technology (IT) closets and electrical rooms in business occupancies?

A: Only if the barriers surrounding the IT closets are designated as being fire rated on the life safety drawings, or by an authority. There is no Life Safety Code requirement to firestop penetrations in barriers surrounding IT closets simply because the closet serves IT equipment. Penetrations in fire rated barriers must be properly firestopped regardless what the barrier serve. I am not aware of a Life Safety Code requirement for IT closets to have fire rated barriers. But, perhaps, local or state authorities have regulations that may require it. You should check with them.

Power Strips

Q: I read the June, 2012 article in HLSC about power strips in healthcare facilities and we have been hesitant to use power strips in patient care areas because the manufacturer’s instructions specifically spell out that they should not be used for life support equipment – and there is no way to know if the power strip will inadvertently be used for life support equipment. I would be interested in your response to this.

A: My response would be to follow the manufacturer’s recommendation. Your concern is valid: You purchased the power strips for a non-life support situation; then unbeknownst to you they could be moved to an area for use in a life support situation. When actual standards that regulate devices are not written, authorities having jurisdiction (AHJs) will resort to other sources; such as UL listings, manufacturer’s recommendations, and the risk associated with the use of the device when determining their appropriateness. It is always best to take a very conservative approach in determining the use of these (and any other medical) devices, not only for accreditation compliance purposes, but also for the safety of patients and staff.

Fire Protection of Equipment Rooms

Q: What is the fire rating supposed to be in the walls of the hospital equipment rooms, such as the generator room, boiler room, chiller rooms, and electrical rooms? We have a disagreement as to what is required and your answer decides who is correct.

A: According to NFPA 110 (1999), section 5-2.1, generator rooms are required to have 2-hour fire rated barriers that protects the room from fire outside the room. Any 2-hour fire rated barrier is required to have 90-minute fire rated doors and frame and if there are any HVAC duct penetrations through the 2-hour barrier, then the HVAC duct opening needs to be protected in accordance with NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating System, which would require a 90-minute fire damper. A boiler room is considered a hazardous area, and according to the 2000 edition of the LSC, sections 18/19.3.2.1, the hazardous area is required to be protected with 1-hour fire rated barriers if it is considered new construction, or 1-hour barriers if it is considered existing and is not protected with sprinklers. Existing boiler rooms that are protected with sprinklers only require smoke resistant walls. All door openings in a 1-hour barrier are required to be ¾ hour fire rated, with fire rated frames. However, unlike the 2-hour barrier, a 1-hour fire rated barrier for a hazardous area is not required to have any fire dampers in a HVAC duct penetration, unless the HVAC penetration is not fully ducted. Electrical rooms typically are not required by the LSC to have fire rated barriers (walls), however NFPA 13 (1999 edition) Standard for the Installation of Sprinkler Systems, section 5-13.11 does permit an electrical room to be protected with 2-hour fire rated barriers in lieu of being protected with sprinklers. Therefore if the room does have fire rated barriers for any reason (including local or state building codes) then it would need fire dampers in the HVAC duct penetration if it is 2-hour fire rated or greater. Chiller rooms typically do not require fire rated barriers, unless the chillers are fuel-fired, then they would require the same protection as the boilers. As always, please check with your local and state authorities to determine if there are other regulations that may affect this situation.

Good Luck!

Locks on Electrical Panels

imagesCATTF4OXI am often asked if locks on electrical panels are required, or where in the world does it say in the Life Safety Code that we need to lock our electrical panels? Well, the quick and short answer, is: As far as I know, there is no direct NFPA standard or Life Safety Code reference that requires electrical panels to be locked. However, that does not mean hospitals cannot be cited for unlocked electrical circuit breaker panels, in some applications. In fact… If left unlocked, it most likely will draw the attention of a surveyor and may lead to a finding.

Section 4.6.1.2 of the 2000 edition of the LSC says any requirements that are essential for the safety of building occupants and that are not specifically provided for in the LSC can be determined by the AHJ. So, Joint Commission has determined that electric circuit breakers for critical equipment, that can be deactivated by unauthorized individuals is a safety risk, and if not addressed with either a lock or a risk assessment, most likely will be written up under EC.02.01.01., EP 1.

 

Joint Commission has addressed this in their FAQ’s found online at www.jointcommission.org under ‘Standards- FAQ’:

Environment of Care (CAMH / Hospitals)

Locking of Electrical Panels

Current | November 24, 2008

Q. Are electrical panels in patient areas required to be locked?

A. While there are no requirements for electrical panels to be locked, the organization should conduct a risk assessment. Generally, electrical panels in certain patient care areas, such as pediatrics, geriatrics and behavioral health units, or public spaces and corridors not under direct supervision should be assessed with consideration given to keeping them locked. Electrical panels located in secure areas that are accessible to authorized staff may not need to be locked.

If you’re looking for suggestions, I would recommend a risk assessment be made of any electrical panel that is not secure from unauthorized access, for two reasons:

  1. The risk assessment will provide the organization a clear course of action to take concerning locking the panels; and:
  2. The risk assessment will provide the organization with paperwork (documentation) that should protect them from any findings in the future.

I would also suggest that you walk your facility, locating those electrical panels that could be accessed by unauthorized individuals, or panels that are not directly supervised, and lock them. If they cannot be locked, or if you believe there is a sufficient safety reason why to not lock them, then write up a simple risk assessment evaluating them and run the assessment by your safety committee.

I will have a post coming up that discusses risk assessments and a sample risk assessment form to use as a template.

Electrical Appliances Not Located in the Patient Care Vicinity

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.