Design Requirements for Clean Area

Q: What are the ventilation, air exchange and air pressure standards for an area in a very old basement that is being used to sanitize equipment in a hospital facility? There is a very small area that is used for cleaning and sanitizing with disinfectants that is right next to the clean storage of these equipment pieces after they are cleaned. Is there also a certain type of flooring that should be used to prevent spores from harboring in cracks in the tile? There is no separation from clean to dirty, passing through the clean area with soiled equipment to get to the sanitizing area. How can this be corrected? I want this area to be compliant and my staff safe.

A: For design requirements, you would be expected to comply with your state and local authorities, as well as the 2010 FGI Guidelines, as applicable. I cannot tell you what your state and local requirements are (they often follow the FGI Guidelines), but here is what the 2010 FGI Guidelines require for ventilation for new construction:

Clean workroom or clean holding: 

  • Positive air pressure;
  • 2 minimum outdoor air changes per hour (ach);
  • 4 minimum total ach;
  • No requirement to exhaust air to the outdoors;
  • No restrictions regarding air recirculated by means of room unit;
  • No restrictions on design humidity thresholds;
  • No restrictions on design temperature thresholds.

Soiled workroom or holding area:

  • Negative air pressure;
  • 2 minimum outdoor ach;
  • 10 minimum total ach;
  • All room air must be exhausted to the outdoors;
  • No recirculating the air by means of room units;
  • There are no design RH thresholds;
  • There are no design temperature thresholds.

Sterilizer equipment room:

  • Negative air pressure;
  • 10 minimum ach total, without any outdoor air requirements;
  • All room air must be exhausted to the outdoors;
  • No recirculating the air by means of room units;
  • There are no design RH thresholds;
  • There are no design temperature thresholds.

The flooring would have to be cleanable with seams that cannot trap dirt, such as welded seams on VCT. There are other products available that would work as well. You have a real problem having soiled equipment pass-through the clean area. These different areas have to be separated physically, otherwise you will not be able to meet the ventilation requirements above. Sounds like you need the assistance of a design professional. I suggest you start with an architect who has experience with healthcare facilities.

Length of Emergency Pull Cord

Q: Can you reference the standard, code or any information from Joint Commission, CMS or any other regulatory organization on the length of the emergency pull cord in a patient used bathroom? Thanks

A: No… The end of the nurse call cords located 4-inches above the floor is an interpretation, not a standard. It is based on the FGI Guidelines, 2014 edition, section 2.1-8.3.7.3 which says a nurse call station shall be activated by a patient lying on the floor in each room containing a patient toilet. Accreditation organizations have used the so-called “4-inch rule” as an interpretation of the FGI Guidelines section 2.1-8.3.7.3.

Since there is no specific standard that identifies the maximum or minimum distance that the end of the call-cord can be from the floor, you can set your own policy, provided it is documented and approved by your respective committees. If your own policy said 6-inches would comply with FGI Guidelines 2.1-8.3.7.3, then the surveyors would have to accept that, since their agencies have not specified the distance between the floor and the end of the cord. But if you don’t have a policy on the distance between the floor and the end of the cord, then the surveyors will assess you based on their own interpretation, which for the most part, is 4-inches. However, if your policy said something that was entirely unreasonable, then the surveyors have the right to find you non-compliant.

I suggest you have a policy that identifies an acceptable range, say 3-inches to 6-inches, to allow a little fluctuation in the field. Get your respective Safety committee and Infection Control committee to approve that policy and then the surveyors cannot cite you for non-compliance unless you’re non-compliant with your own policy.

Strange Observations – Wall Mounted Signs

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

The discharge door for a stairwell opened out onto the 1st floor corridor, where egress was just down the corridor. (This is permitted by section 7.7.2 of the 2012 LSC, provided they met all of the other requirements).

As the picture indicates, when the stairwell door is fully opened, it sticks out into the corridor about half the width of the door. This can cause a momentary obstruction to people in the corridor when the door is open.

The facilities department thought it would be a good idea to warn people that the door may be a problem when open and created this sign on a swivel that warns people. To be sure, the sign does swing if anyone came into contact with it, but when it is in its normal position, it projected more than 4-inches into the corridor.

Even though the intentions for the sign were good, it does violate the maximum 4-inch corridor projection rule adopted by CMS, and therefore it was written up.

Hole in the Wall

Q: I have a surgery suite that had a hole punched into the wall by the door knob. Is there anything in LSC that states ” if a hole is made in a surgery wall the drywall needs to be replaced from stud to stud”, not just repair the hole?

A: No… The LSC does not concern itself with the way the walls are repaired. When it comes to walls, the LSC only concerns itself with identifying which walls must be smoke resistant, fire-rated, or smoke rated. The UL listings for the walls will determine how the wall is constructed, and repairs to the wall must follow the same UL listing.

Now, if the wall with the door knob hole is only required to be smoke resistant, then you can seal the hole with any type of patch that makes the wall resistant to the passage of smoke. But if the wall is fire-rated, or is required to be a 1-hour rated smoke barrier, then you must excise the hole from stud to stud, insert a new piece of gypsum board, and screw, tape and apply joint compound in accordance with the UL listing for that wall.

I’m sure your Infection Control practitioner would have a lot to say about a hole in a wall in surgery.

Strange Observations – Ceiling Penetrations

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

This picture was taken in an electrical room. Where the conduits extend upwards and penetrate the suspended ceiling, the gaps around the conduits are too large.

Most surveyors will use the NFPA 80 maximum 1/8-inch gap rule fire door clearance to frames as a standard for the maximum gap around conduit penetrations, where the ceiling is required to act as a membrane for smoke detectors or sprinkler heads.

In situations like this, the easiest and best solution is to remove the suspended ceiling from the electrical room, and relocate the lights in the ceiling to the deck above.

Fire Damper Removal

Q: I have a building that is fully sprinklered and has full protection from the fire alarm system, with multiple floors. The age of the building is 40+ years and when it was constructed it was not fully sprinklered and had fire and smoke dampers (some still pneumatic) to control the spread of fire and smoke. Our last damper inspection revealed that we have 44 dampers that are not functioning or they are inaccessible to inspect. My question is, since we are now fully protected by sprinklers and are using the rule for smoke compartments on the floors, are all the dampers we have are necessary or can we possible take some out of service? What is the rule on this situation?

A: That’s tough question to answer without actually seeing the facility, but I’ll take a stab at it: If the smoke compartment layout has been re-designed, and you find that some existing smoke barriers are no longer required, then the smoke dampers located in those smoke barriers could be removed, pending approval from your state and local authorities on hospital construction. However, if existing smoke barriers remain in use but you would like to remove the smoke dampers because section 18.3.7.3 (2) of the 2012 LSC says smoke dampers are not required in new construction smoke barrier where the HVAC duct is fully ducted and the adjoining zones are fully sprinklered…. That may not happen because the IBC codes do not allow this. If you are required to comply with the IBC codes, then this will be a problem. Check with your state and local authorities to see if they require compliance with the IBC codes.

Delayed Egress Locks

Q: Our hospital is not fully sprinklered and is not fully smoke detected, but we want to install an infant security locking system in our Mother/Baby unit. I discussed this with our vendor who wants to sell us the infant security locking system, and he says we qualify for delayed egress locks because being 100% fully sprinklered is not the only criterion for compliance. He says we comply because we demonstrate the existence of an approved, supervised automatic fire detection system by having an automatic fire detection system in our hospital, so that should allow the installation of the infant security locking system. The vendor also said as long as the local AHJ approves the installation, that’s all we need, because the local AHJ has the final word. What do you say?

A: NFPA 101 Life Safety Code, 2012, section 7.2.1.6.1 is rather clear: Among other requirements, in order to have delayed egress locks, you need one of the following:

  • The building needs to be fully protected throughout by an automatic sprinkler system, or;
  • The building needs to be fully protected throughout by an automatic fire detection system.

Being fully protected throughout with automatic sprinklers is obvious – you need full sprinkler coverage everywhere in the building. But it appears the term ‘being fully protected throughout by an automatic fire detection system’ is not so obvious. If you are not fully protected with sprinklers, then section 7.2.1.6.1 requires a smoke detector in all occupiable areas. This is explained in section 9.6.2.9 of the 2012 LSC. This means a smoke detector must be inside every room, every sleeping room, every procedure room, every corridor, every office, every conference room, every utility room, every lounge, every classroom, every work-room, every mechanical room, etc. In my 40-years of doing this work, I’ve yet to see a hospital qualify for this in regards to installing smoke detectors in all occupiable areas. If you believe your hospital meets the requirements for being fully protected with smoke detectors, then I would like to schedule a visit and take a look, because I’ve never seen that before.

Please understand the way your vendor described it “demonstrate the existence of an approved, supervised automatic fire detection system”, does not meet the description of being fully protected throughout by an automatic fire detection system. All hospitals have an approved, supervised automatic fire detection system, because the LSC requires that. But no hospital (so far that I have seen) has a smoke detector in all occupiable areas. It’s not required and it is too costly to install. Sprinklers are far cheaper.

Your vendor is correct, though: Sprinklers are not the sole criterion for the installation of delayed egress locks. But, it is one of two criteria, and so far, no hospital is choosing to go with the other choice (smoke detectors). Even if you could afford to install smoke detectors in every occupiable areas, the hospital would likely not be able to afford the maintenance (testing & inspection) and all of the false alarms that go with it.

By the way… the phrase “the local AHJ has the final word” is not accurate. I appreciate the respect that the vendor is trying to say, but all AHJs have the final word, not just the local AHJ. The typical hospital has many (between 5 and 8) AHJs that they have to comply with regarding the Life Safety Code:

  • CMS (Federal)
  • Accreditation organization
  • State licensing agency
  • State agency in charge of hospital construction
  • State fire marshal
  • Local fire authority
  • Local building code authority
  • Insurance company

All AHJs are equal. No one AHJ can override the decision of another AHJ. Any AHJ can decide to interpret the LSC in the way they deem necessary and if it disagrees with another AHJ, then so be it. The hospital must comply with the most restrictive interpretation. So, saying the local AHJ has the final word is not accurate; all AHJs have the final word. For example: If the local AHJ said it is okay to install delayed egress locks for infant security (because nobody wants to see infants stolen), even though the building is not fully sprinklered and not fully smoke detected, that’s not okay with other AHJS like CMS, your accreditation agency and your state agency on hospital construction. So, the hospital cannot do that, because they have to follow the most restrictive interpretation.

I see other hospitals that are not fully sprinklered or fully smoke detected use infant security systems but they do not install the door locking hardware. So, it operates like a warning system. If the hospital does not want to invest in being fully protected with sprinklers (or smoke detectors), then that is their only option. It is an incentive to become fully protected with sprinklers.

There’s A New Form on the ‘Tools’ Webpage

Just a quick note to let you know there is a new form available to you for free, on the ‘Tools’ webpage called “Fire/Smoke Damper Test”. Due to multiple requests by readers, we’ve developed a simple template for you to use in documenting your fire damper and smoke damper test results.

Check out this and other forms and documents that are available for you at no cost to help maintain your facility to be Life Safety Code compliance.

Occupational Therapy Kitchens

Q: Do occupational therapy kitchens need to meet NFPA 96 standards? This unit will be a new build and will fall under business occupancy requirements, but the Life Safety Code for new business occupancies refers me back to 9.2.3, which refers me to NFPA 96.

A: Is the cooking equipment really ‘commercial cooking equipment’? For an occupational therapy kitchen, you would be using residential cooking equipment, would you not? Also, is the cooking equipment that is used for occupational therapy ever turned on…? Do they ever actually cook or bake anything on the stove?

If it were a healthcare occupancy, the answer is a no-brainer, since section 19.3.2.5.2 specifically says residential cooking equipment that is used for food warming or limited cooking does not have to meet the requirements of 9.2.3. While that section may have been written for food warming equipment in staff lounges, one could apply it towards occupational therapy kitchens as well.

But you may have a good case with sections 38/39.3.2.3 (3), which says something similar and exempts cooking equipment used only for food warming from having to meet section 9.2.3. There are a few other points that would prevent you from having to meet NFPA 96 requirements. According to NFPA 96-2011, section 1.1, it says the following regarding residential equipment:

  • 1.1.2 This standard shall apply to residential cooking equipment used for commercial cooking operations.

(You’re not using this residential cooking equipment for commercial cooking operations, so therefore, NFPA 96 does not apply).

 1.1.4* This standard shall not apply to facilities where all of the following are met:

(1) Only residential equipment is being used.

(2) Fire extinguishers are located in all kitchen areas in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

(3) The facility is not an assembly occupancy.

(4) The authority having jurisdiction has approved the installation.

(Make sure you comply with the above four items and you do not have to comply with NFPA 96.)

So, I think you have enough to go on to convince an AHJ that a NFPA 96 exhaust hood is not required for occupational therapy residential cooking equipment in business occupancies.

Smoke Dampers in Smoke Partitions?

Q: When comparing smoke dampers in smoke barriers vs smoke partitions, section 8.5.5.2 requires smoke dampers (with exemptions) for penetrations by ducts or air-transfer openings in a smoke barrier. Section 8.4.6.2 (smoke dampers in smoke partitions) only indicates air-transfer openings as required to have smoke dampers, with no mention of ducted openings, which we interpret to mean that ducted openings in a smoke partition do not require smoke dampers. However, we have been repeatedly told by mechanical engineers that smoke dampers are required for all ducts, transfer ducts, and air-transfer openings that pass through a smoke partition – which interpretation is correct?

A: It appears to me that your mechanical engineers are confusing smoke partitions with smoke barriers. To be sure, air-transfer openings are prohibited in corridor walls (which are smoke partitions) in healthcare occupancies, according to section 19.3.6.4.1 of the 2012 LSC. Also, section 19.3.7.3 (2) exempts smoke dampers in fully-ducted penetrations in smoke barriers, where the smoke compartments served by the smoke barriers are fully protected with Quick Response sprinklers. I do not see where smoke dampers are required in HVAC ductwork in smoke partitions.