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-Rated Doors in Fire-Rated Barriers?

Q: If the health care facility is fully sprinklered do doors in a corridor, where the walls are fire rated, do the doors have to be fire rated? I read in NFPA 101 that they do not….

A: Where do you read that…? I would like to know what you’re reading to be able to provide you with a better answer.

Generally speaking, where you have a fire-rated barrier, you usually need to have fire-rated doors in openings in the fire-rated barriers. But there are some exceptions:

  • Fire-rated barriers that separate an atrium from the rest of the facility are not required to have fire-rated doors.
  • Corridor walls in existing healthcare occupancies located in a smoke compartment that is not fully sprinklered, are required to be 30-minute fire-rated and the corridor doors are permitted to be non-fire-rated, but must limit the passage of smoke.
  • Some building codes that require fire-rated corridor walls do not require fire-rated doors in the openings. But this is not a LSC issue.
  • Smoke barriers that separate smoke compartments are required to be rated (1-hour for new construction) but doors in smoke barriers are not required to be fire-rated.

 

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.

Fire-Proofing Structural Steel

Q: Since our last survey we were introduced to an epoxy based intumescent fire proofing product to repair damaged areas of vermiculite fireproofing on our structural steel that had bare areas from years of wear. Two weeks-ago we had a “mock” survey by my corporate representative and while he seemed to like the application process, he is not sure that we could pass our survey when the real surveyors come. He suggested that we think about having it repaired with the vermiculite product. What do you think? Any help would be greatly appreciated.

A: This issue is not clearly understood among the different AHJs, let alone their surveyors. I can say that many surveyors would not know what they are looking at if you had mixed fire-proofing products on the same piece of structural steel.

But, to be sure, your representative who conducted the mock survey is correct: You cannot mix and match different types of fire-proofing material to repair missing fire-proofing on structural members of your building. While you will not find a specific code or standard that says this, it is an interpretation of the UL listings for fire-proofing structural members of the building. Simply stated; There is no UL listing that allows you to mix different UL listed products to form a contiguous fire-proofing protection on the structural member. If there is, I have not seen or heard about it.

So, heed the advice from your mock surveyor and only put back the same type of fire-proofing material that was originally applied. Sounds to me, that your mock surveyor should be a real surveyor for CMS or one of the accreditation organizations. He seems to know what he is looking at.

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.

Strange Observations – Aisle Width

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

This is an equipment room. It appears to be a water room of some sort as I see a water tank and some water filters. I also see boxes and ‘stuff’ blocking access into and out of this room.

The problem with this situation is the room does not have a clear aisle width. Even though this is an equipment room, you still must maintain a clear aisle width of at least 28-inches for existing conditions, and 36-inches for new construction.

Remember: The exit-access is not limited to the corridor. Every room has an exit-access, and the appropriate aisle width must be maintained in those areas. Section 7.3.4.1.1 and 7.3.4.1.2 of the 2012 Life Safety Code provides the standards that regulate the aisle width.

Last Day to Register for… Compliance One Presents Keyes Life Safety Boot Camp

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Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel.

NOTE: CEUs will be awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Presented by:

Fire Drills

Q: Is it required to activate the fire alarm system in our hospital whenever a fire drill is conducted for AM or PM Shift?

A: Yes. According to section 19.7.1.4 of the 2012 Life Safety Code, fire drills in healthcare occupancies must include the transmission of a fire alarm signal and simulation of emergency fire conditions. The Annex explains that the purpose of the drill is to test and evaluate the efficiency, knowledge, and response of the healthcare personnel in implementing the emergency fire response plan. The purpose is to not excite or disturb the patients, so doors to patient rooms should be closed. Between the hours of 9pm and 6am, you still must activate the fire alarm system during a drill, but you have the option to silence any audible notification devices.

Strange Observations – Exit Enclosure

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

This is not corridor, but rather an exit enclosure to a stairwell. There was a construction project in progress and to achieve a negative air pressure in the project area, the contractor cut a hole (twice) in the 2-hour fire-rated barrier for the exit enclosure to run the temporary flex duct to the exhaust fan.

Section 7.1.3.2.1 (10) of the 2012 LSC does not allow penetrations into and through an exit enclosure for this purpose, even on a temporary basis.

If you’re asking what the hospital should have done if this was their only option to create negative air for the project, I would say they could have set-up a HEPA filter negative air machine inside the project area, and discharge the air from the HEPA blower to an adjacent corridor. Not the best solution, but one that is far better than making penetrations into the exit enclosure.

There is also the issue of headroom which must be at least 7-foot 6-inches, according to section 7.1.5.1.

Door Lever Hardware

Q: Is there a Life Safety Code requirement for door lever hardware to have a return, so as to not “hook” passing clothing, straps, purses during emergency evacuations? I swear I remember this for healthcare occupancies from somewhere, but can no longer find it in the Life Safety Code.

A: No, the 2012 Life Safety Code does not require a return on door lever handles to prevent hooking clothing during egress. But my good friend Lori Greene (www.idighardware.com) tells me the return is only required by the California Referenced Standards Code, which says: Levers.  The lever of lever-actuated levers or locks shall be curved with a return to within 1/2″ of the face of the door to prevent catching on the clothing of persons during egress. Since this is not a requirement of the NFPA or ICC codes or standards, it would only apply in California.