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.

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.

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.