Ambulatory Suites

Q: Am I allowed to have a suite inside an area designated as an Ambulatory Occupancy? And for clarification, do suite boundary walls need to be one-hour fire rated?

A: Yes… you are permitted to have a suite in an ambulatory health care occupancy. Look at section 20/21.2.4.3 which permits suites in AHCO, but any suite over 2,500 square feet must have two remotely located doors from the suite. No… Suite boundary walls are not necessarily required to be 1-hour fire-rated. They are required to be equal to the fire-resistive rating of the corridor walls. For new construction, corridor walls would be a minimum of 1-hour fire rated barriers, unless one of the following exists:

  • Where exits are available from an open floor area
  • Within a space occupied by a single tenant
  • Within buildings that are fully protected with automatic sprinklers

For existing construction, there are no requirements for corridor walls, so therefore there are no requirements for suite boundary walls.

ASC Smoke Detector Sensitivity

Q: We are a service contractor that is attempting to obtain a contract with a new client that is an Ambulatory Surgery Center. The ASC told us they never had their smoke detector sensitivity checked. We told them it was a CMS requirement to have the smoke detector sensitivity checked every 2 years, but they tell us they want us to check it every 5-years as that is what their current service contractor is telling them. How can they be in business for over 12 years and no one ever checked their smoke detector sensitivity? Have the NFPA standards changed regarding smoke detector sensitivity testing?

A: Ignorance, and a lack of understanding of the codes and standards. And a lack of enforcement by their AHJs…that’s how it could be missed for 12 years. This is not surprising. But to answer your last question: No, testing intervals have not changed in NFPA 72. Sensitivity of the smoke detectors has to be checked one year after installation, and then every other year thereafter. After the second required calibration test, frequency may extend to every 5 years provided the sensitivity tests indicate the devices have remained within its listed and marked sensitivity range.

EM Lighting in Out-Patient Facilities

Q: We have out-patient clinics classified as business occupancies. Are we required to have emergency egress lighting? If so what section of the 2012 or 2015 NFPA Life Safety Code outlines the requirement?

A: It depends. For new business occupancies section 38.2.9.1 of the 2012 LSC says emergency lighting shall be provided where any one of the following conditions exists:

  1. The building is three or more stories in height;
  2. The occupancy is subject to 50 or more occupants above or below the level of exit discharge;
  3. The occupancy is subject to 300 or more total occupants.

For existing business occupancies section 39.2.9.1 of the 2012 LSC says emergency lighting shall be provided where any one of the following conditions exists:

  1. The building is three or more stories in height;
  2. The occupancy is subject to 100 or more occupants above or below the level of exit discharge;
  3. The occupancy is subject to 1000 or more total occupants.

The emergency lighting must be installed in accordance with section 7.9, which discusses battery-powered emergency lights and those egress lights powered from generators. According to 7.9.2.2, new emergency power systems for emergency lighting shall be generator power, with a Type 10 (meaning no more than 10 seconds to transfer power), Class 1.5 (which means must provide emergency power for a duration of 90-minutes) and rated for Level 1 (which means the system shall be installed where failure of the equipment to perform could result in loss of human life or serious injury). Level 1 systems are described in NFPA 110 as rotating equipment energy converters powered by prime movers (i.e. generators). Existing condition emergency lights could be powered by battery-powered emergency lights.

ASC Soiled Utility Room

Q: How does one handle a “Soiled Utility” room in an Ambulatory Healthcare Occupancy? If it is a small storage room without large volumes of flammable liquids, but perhaps containing soiled linens, are there any special fire protection features that need to be included?

A: Soiled utility rooms in ASCs are treated differently than they are in hospitals and healthcare occupancies. Where chapters 18 and 19 specifically identify soiled utility rooms as hazardous areas for healthcare occupancies, chapters 20 and 21 do not for ambulatory healthcare occupancies.

But chapters 20 and 21 refer to chapters 38 and 39 for “Protection from Hazards” and it does identify ‘storage rooms’ as a hazardous area and must comply with section 8.7. Section 8.7.1.1 requires the hazardous room (i.e. soiled utility room in ASC) to be protected in one of the following two ways:

  1. Enclosing the room with 1-hour fire rated barriers, that would include a ¾ hour fire rated door assembly that is self-closing and positive latching, or:
  2. Protect the room with sprinklers.

That’s what you need to do.

Fire Drills in ASC Located in a Shared MOB

Q: We have 13 off-site Ambulatory Surgery Centers and some are in stand-alone buildings where they are the only occupant and some are in high rise Medical Office Buildings (MOB). For quarterly fire drills, are we to have staff activate the building general fire alarm system for every drill? For the stand alone sites I do not see a problem with this, but for the others in MOBs we do not own where 90% of other tenants are business occupancies, cancer patients, rehab centers, etc. Are we not creating unnecessary stress by dumping the building four times a year, which is exactly what would happen if we pulled the pull station in a MOB? I reached out to the supervisor of the surveyor that cited us, but wanted to gain another perspective.

A: The surveyor was correct in citing you for not activating the fire alarm system during a fire drill. It is a key requirement that provides staff with knowledge and understanding what an actual fire alarm sounds and looks like.

I do see and understand your dilemma in those MOB’s where your organization is not the only entity in the building. But haven’t you discussed this issue with your landlord yet? There are ways to re-program the fire alarm occupant notification system (i.e. strobes, horns, chimes, etc.) to activate only in your area. Yes. It may cost some funds to do so, but that is part of the cost of doing business in a building that is shared with other entities.

Also, have you discussed the option of conducting building-wide fire drills with the other occupants? Since you’re an ASC you must do quarterly fire drills and the other entities may be business occupancies which only require annual fire drills. But if you scheduled the drills at a time when it is least likely to disrupt operations of everyone, then the other entities may be more accepting of your situation.

The bottom line: You must activate the fire alarm system when conducting a fire drill. Discuss this challenge with the other tenants and see if they are willing to accommodate you at various times (i.e. early in the day or late in the afternoon). If not, then invest in making the fire alarm system activate only in your area during a fire drill.

You do have options…

Suites in AHCO

Q: We recently had a surveyor tell us that suites are not allowed in ambulatory healthcare occupancies. Can you help explain this and any code references that support your opinion?

A: Well… that surveyor is mistaken. Suites are definitely permitted in ambulatory health care occupancies (AHCO). Sections 20/21.2.4.3 of the 2012 LSC specifically permit suites and says any site larger than 2500 square feet must have at least two exit access doors remotely located from each other.

The term ‘remotely located’ is defined by section 7.5.1.3.2 which says the two exits must be located at a distance from one another not less than one-half the length of the maximum overall diagonal dimension of the suite, measured in a straight line between the nearest edges of the exits. In a fully sprinklered building, section 7.5.1.3.3 says it is 1/3 the length of the maximum overall diagonal dimension of the suite.

There are no size limitations on suites in AHCO. And they are not prohibited in business occupancies either, even though there is no advantage to having them in business occupancies. I suggest you ask the surveyor (if he/she is still with you) to show you where in the LSC it prohibits suites in AHCO. I also suggest you ask your state and local authorities if they have any restrictions that would prohibit suites in AHCO.

Contiguous Facilities Used by Inpatients

Q: We have a building that is next to our hospital that is an imaging center, that is not a healthcare occupancy. Are we allowed to take patients from the hospital into the imaging center for diagnosis purposes?

A: Section 19.1.3.4.2 of the 2012 Life Safety Code says ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies shall be permitted to be used for diagnostic and treatment services of inpatients who are capable of self-preservation. This section is new to the 2012 Life Safety Code and was not found in previous editions. The Handbook for the 2012 Life Safety Code says this requirement is intended to permit one, two, or three ambulatory inpatients to visit doctor’s offices simultaneously in an adjacent business occupancy, for example, without requiring classification of the business occupancy as a health care facility.

But, there are caveats to this section that need to be reviewed.

  1. Section 19.1.3.4.2 says the facility needs to be contiguous to the healthcare occupancy. This means it has to be physically connected to the healthcare occupancy. Does your imaging center meet that requirement?  I do not believe a portable trailer would qualify as being contiguous, if that is what you have. I also do not believe it would be acceptable if there is a different occupancy classification between the healthcare occupancy and your imaging center. Make sure the imaging center is actually physically connected to the healthcare occupancy.
  2. Only ambulatory inpatients may be taken from the healthcare occupancy into the contiguous facility for diagnosis or treatment services. This would mean patients need to be able to get up and walk out of the building under their own power without the assistance from others, and they can take action for self-preservation without the assistance from others. This does not mean they have to walk under their own power, but only that they are able to do so.

My recommendation to you is to use section 19.1.3.4.2 to your advantage. If your imaging center qualifies under 19.1.3.4.2 and the inpatients going there are fully ambulatory and capable of self-preservation, and you have no more than 3 inpatients in the contiguous facility at a time, then you would qualify under 19.1.3.4.2. Use it until you are told by an AHJ that you cannot use it. So far, I have not seen anything from CMS or the accreditation organizations that would prevent you from using this section of the LSC to your advantage.

Ambulatory Healthcare Occupancy Fire Drills

Q: My question is with an ambulatory healthcare occupancy classification. Do you need just one fire drill per quarter or do you need one fire drill per shift per quarter? The ambulatory healthcare occupancy has a 24hr ED and also has some departments that have three shifts, ie: EVS, Security and Medical Imaging.

A: According to section 21.7.1.6 of the 2012 Life Safety Code, fire drills are to be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and the emergency action required under varied conditions. So, the answer is once per shift per quarter.

Fire Extinguishers in an ASC

Q: We have a 1400 square foot ambulatory surgical center (ASC). In the plans there are only 5 Fire Extinguishers throughout the facility. I looked at 2012 Life Safety Code and the referenced NFPA 10-2010 but still not sure. What are the locations and how many fire extinguishers should be in this 3 operating room 1400 square foot ASC?

A: The placement of portable fire extinguishers is determined on the length of travel distance to get to a fire extinguisher…. It is not determined by the total square footage of the facility. According to NFPA 10-2010, the maximum travel distance to get to a fire extinguisher is dependent on the classification of the fire extinguisher, the capacity of the fire extinguisher, and the potential level of hazard from the fire.

Class A fire extinguishers are for normal combustibles, such as paper, wood, plastic and linens. The maximum travel distance to get to a Class A extinguisher is 75 feet for all capacities of Class A extinguishers, and all potential levels of hazard from the fire. That means you need a Class A extinguisher within 75 feet of all paper, wood, plastic and/or linen. Since paper, wood, plastic and linen are nearly everywhere in a healthcare facility, you will need a Class A fire extinguisher within 75 feet of everywhere inside the facility.

Class B fire extinguishers are for flammable liquids, such as alcohol, alcohol-based hand-rub (ABHR) solution, and xylene. The maximum travel distance to get to a Class B extinguisher is either 30 feet or 50 feet, depending on the capacity of the Class B fire extinguisher, and the level of hazard of the potential flammable liquid fire. The capacity of a Class B extinguisher is pre-determined by the manufacturer, and is identified on the extinguisher label. Usually, it is determined by the ability of the extinguisher to extinguish a fire, so the quantity of the product in the extinguisher is a factor. According to Table 6.3.1.1 of NFPA 10-2010, where the level of the potential hazard is low, a 5-B extinguisher is only permitted a 30-foot travel distance, but a 10-B extinguisher is permitted a 50-foot travel distance. Similarly, if the level of potential hazard is moderate, then a 10-B extinguisher is permitted a 30-foot travel distance, and a 20-B extinguisher is permitted a 50-foot travel distance.

Class C fire extinguishers are for electrical fires. An electrical fire is started by electricity, but the actual substance that burns is either Class A (normal combustibles) or Class B (flammable liquids). Therefore, where potential electrical fires are expected, then a Class C extinguisher is needed, based on the maximum travel distance to get to the extinguisher on either Class A or Class B standards.

Class D fire extinguishers are for combustible metals such as magnesium, zirconium, and potassium, which a typical healthcare facility does not have. Therefore, Class D extinguishers are not required if you do not have any of the combustible metals.

Class K extinguishers are for fires from cooking appliances that involve combustible cooking media (vegetable or animal oils and fats). These are found in kitchens and the maximum travel distance to get to a Class K extinguisher is 30 feet.

The determination of the level of hazard for a Class B potential fire is subjective and could vary depending on the surveyor and authority having jurisdiction (AHJ). For a healthcare facility, a low level of hazard would be areas where individual (or low quantities) of ABHR dispensers or bottles are located, and low levels of alcohol or xylene are located. A potential hazard of flammable liquids is moderate where larger quantities of flammable liquids are stored. But be careful: Based on the information in NFPA 10-2010, you would need Class B extinguishers with a 10-B rating with a maximum travel distance of 50 feet to cover potential fires from ABHR dispensers. This is often overlooked by designers when they are placing portable fire extinguishers in new facilities. Instead of the usual 75 maximum travel distance to get to a Class A extinguisher, you will need to place the Class B extinguishers with a maximum 50-foot travel distance to cover potential fires from ABHR dispensers.

There are fire extinguishers that have the rating to fight Class A, Class B, and Class C fires all in one extinguisher. These are typically ABC dry powder extinguishers, but there are other media types, such as clean agent extinguishers that can achieve an ABC rating. But dry powder extinguishers are not desirable in operating rooms where the possibility of infection is high if the dry powder extinguisher is activated. Therefore, many healthcare facilities rely on water-mist Class A:C extinguishers and a carbon dioxide (CO2) Class B inside the operating room. But you would have to make sure the water-mist extinguishers are charged with distilled water and nitrogen to prevent the growth of pathogens.

Other healthcare facilities do not use water-mist extinguishers in the operating room and rely on the sterile water in a bowl in the sterile field to extinguish any Class A fires that may occur. They then find Class B:C extinguishers to cover Class B and Class C potential fires. Keep in mind, there is no requirement that portable fire extinguishers have to be located inside each operating room. The fire extinguishers just have to be located within the maximum travel distance permitted for each classification of extinguisher, capacity of the extinguisher, and the level of hazard for the potential fire. But be careful: Some operating rooms are rather large, and it might be more than 30 feet to travel from the far corner of the operating room, to the Class B extinguisher in the hallway.

Class K extinguishers are required in kitchens, and the maximum travel distance to get to a Class K extinguisher is 30 feet. A placard needs to be installed above the Class K extinguisher that informs the staff to activate the kitchen hood suppression system first, before using the Class K extinguisher.

Contiguous Facilities

Q: If an inpatient in a hospital (healthcare occupancy) is taken into a building that is not a healthcare occupancy for say CT or MRI, does this building have to then meet the requirements in the Life Safety Code for a healthcare occupancy?

A: According to section 19.1.3.4.2 of the 2012 LSC, it says ambulatory care facilities, medical clinics, and similar facilities that are contiguous to healthcare occupancies shall be permitted to be used for diagnostic and treatment services of inpatients who are capable of self-preservation. This is new for the 2012 LSC and was not found in the 2000 edition, so not everyone may be aware of this.

But the kicker is “inpatients who are capable of self-preservation”. The inpatient really does need to be capable of taking action for their own self-preservation without the assistance of others.

All healthcare occupancy inpatients, even if it is just one inpatient, that are brought into a contiguous facility that is not a healthcare occupancy for diagnostic or treatment purposes must be capable of self-preservation. Otherwise, it is not permitted.