Fire Drills

Q: There is a lot of confusion on how many fire drills we have to complete. We have 3 towers where there is healthcare, all connected, but different building names. Do we only need to complete 1 fire drill per shift per quarter in EACH building or can we combine the 3 towers into one healthcare? They are breaking out each tower and conducting the required amount in each building, which seems overkill.

A: The intent of the Life Safety Code is to conduct fire drills once per shift per quarter in all healthcare occupancies per building. If you have more than one building on campus that contains healthcare occupancies, then you would have to conduct separate fire drills for each shift and each quarter in each building.

However, if the buildings that contain healthcare occupancies are contiguous (connected together) and there is no fire rated barrier serving as a separation barrier between the buildings, then you could do one fire drill per shift per quarter that would cover all the buildings.

A separation barrier would be a fire-rated barrier that is vertically aligned (meaning the barrier does not extend horizontally) from the lowest floor to the roof. The fire rating of the barrier could differ depending on the applicable codes and standards, but the NFPA 101 Life Safety Code would require at a minimum a 2-hour fire rating.

Strange Observations – No ‘NO EXIT’ Sign

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

The door in the picture is to a courtyard where patients may go and enjoy the out-of-doors. The problem is, there is no ‘NO EXIT’ sign on the door, and in my opinion the door could be confused for an exit door.

The size and make-up of the ‘NO EXIT’ sign is very specific: The word “NO” must be 2-inches tall, and the word “EXIT” must be 1-inch tall. The word “NO” must be over the top of the word “EXIT”.

The reason the word “EXIT” is smaller than the word “NO” is the technical committee who wrote that portion of the Life Safety Code wanted people to read the word “NO” before they read the word “EXIT” while approaching the door.

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.

ABHR Dispensers

Q: In a business occupancy building, can alcohol based hand-rub dispensers be placed over carpeted area with no sprinklers?

A: Maybe yes and maybe no… It all depends on which AHJ is looking at your business occupancy.

Section 19.3.2.6 (8) of the 2012 LSC requires ABHR dispensers that are mounted over carpets, to only be in sprinklered smoke compartments. But this only applies to healthcare occupancies, and section 21.3.2.6 has similar language for ambulatory healthcare occupancies. The problem is, there is nothing written in chapters 38 or 39 regarding the installation of ABHR dispensers in business occupancies.

Since nothing is written in the business occupancy chapters, one may think there are no limitations, and the ABHR dispensers may be placed wherever you want without regard to regulations. Some AHJs may agree, and allow the ABHR dispensers be installed over carpet in an unsprinklered area. But the AHJs with healthcare experience and knowledge probably will not, based on their understanding of chapters 19 and 21. And, this is not an incorrect process, since they know these regulations regarding ABHR dispensers and can apply them to a business occupancy based on safety-related issues. Section 4.6.1.2 supports this concept.

But please understand, section 8.7.3.2 of the 2012 LSC prohibits the handling and storage of flammable liquids where it would jeopardize egress. This means ABHR dispensers are not permitted in egress corridor. Chapter 18/19 and 20/21 specifically permit ABHR dispensers in corridor so that over-rides section 8.7.3.2. But the business occupancy chapters 38 and 39 do not have this language to over-ride 8.7.3.2, so that means ABHR dispensers are not permitted in egress corridor of business occupancies.

My advice is follow the same regulations for ABHR dispensers found in 19.3.2.6 for business occupancies, with the exception that ABHR dispensers are not permitted in egress corridors of business occupancies.

Happy Birthday…. to me

Well, no, it’s not my birthday, but 10-years ago today I published my first post on this website. In 10 short years, I have made over 1,150 postings, and answered gobs of questions in the process, some of them correctly.

So, in a way, it is the 10th birthday of the Keyes Life Safety website. I’ve enjoyed every minute and I hope we can go another 10-years.

Thanks for being a reader…

Sincerely,

Strange Observations – Sprinkler in the Alcove

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

The good news is you have an alcove in the corridor where you can store linen carts. The bad news is a sprinkler head was installed in the alcove preventing you from storing linen carts.

In this photo, the top of the linen cart is too close to the sprinkler deflector. You must maintain at least 18-inches clearance underneath the sprinkler head.

I’m not an expert on sprinkler design, but I suspect they would not need a sprinkler head in the alcove, if another sprinkler head was in close proximity.

Stairwell Signage

Q: With the new 2012 Life Safety Code adoption, my question is around the stairwell signage and 7.2.2.5.4.1. Hospitals are confused whether they have to replace all their signs to meet this new code requirement, or if they are grandfathered-in, and not have to comply. From what I interpret from the code, this would be for new stairwells only… is this correct?

A: No… This applies to all new enclosed stairs serving three stories or more, and all existing enclosed stairs serving five stories or more. There is no ‘Grandfathering’ in the Life Safety Code. There are requirements for new construction (Chapter 18) and there are requirements for existing conditions (Chapter 19), but other than that, there is no ‘Grandfathering’.

When new editions of the Life Safety Code are adopted, facilities must comply with new requirements that apply to existing conditions. Just because the building was compliant with the Life Safety Code at the time of original construction, does not permit the building a ‘pass’ on meeting new requirements that apply to existing conditions.

 

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.

Alcoves

Q: Is there a limit to the size an alcove can be in a smoke compartment right off of the corridor? I understand equipment can be stored in alcoves but is there a definition of an alcove? I have a one hundred square foot room that was once required to be a remote nurse station, but the area is no longer used as a remote nurse station. There is no door to the room and the opening to the corridor is 6 feet wide. Am I allowed to store wheeled equipment (i.e. wheelchairs, patient lifts and crash carts) not in use in this area?

A: Crash carts are permitted to be left unattended in the required width of the corridor, but your question is valid for the other items. Generally speaking in healthcare occupancies, corridors must be separated from all other areas and rooms. But take a look at section 19.6.3.1 of the 2012 Life Safety Code. There are nine (9) exceptions to the LSC requirement that the corridor must be separated from the rest of the facility.

Depending on certain variables, such as sprinkler coverage, smoke detection, size of the open area, etc., you may be able to qualify for one or more of the exceptions. However, you cannot store any combustibles in this room that is open to the corridor. That means no bed storage (because mattresses are combustible) and no supply carts with combustible supplies can be stored in these rooms.

You will have patrol this area often to ensure it is maintained properly. But to answer your question, I have not seen any limitations on size of alcoves in corridors. And one of the exceptions to 19.3.6.1 says spaces unlimited in size may be open to the corridor if you meet all of the requirements.

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.