Ignoring Life Safety Code for Emergency Situations

Q: My hospital is preparing for COVID-19. I’m at odds with the clinicians who believe that the pandemic is a special situation, meaning that Life Safety Code can go by the wayside in order to be prepared to receive and care for contagious patients. For instance, clinicians have decided to move waiting chairs into corridors to provide what is considered “social distancing.” Another example is the plan to place plastic sheeting barriers in corridors so that the hospital can be split into a clean and dirty zone. What would be your recommendation for these situations? Can the Life Safety Code be ignored for emergency situations?

A: Yes, but only when the Emergency Response Plan is activated. You still must maintain a level of safety for staff, visitors, and patients, but that level of safety is a moving target when there is a disaster to accommodate. Having plastic sheeting in an exit access corridor is certainly a violation of the Life Safety Code, but it may very well be necessary when there is a disaster. This is a judgment call and one that should be addressed in the Emergency Response Plan and approved by the person in charge of the disaster response team, not the physicians.

You will not find this written in any standard that I am aware of, but is based on years of experience working with Centers for Medicare & Medicaid Services (CMS) and The Joint Commission.

Brad Keyes
Brad Keyes, CHSP

Brad is a former advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor. He guides clients through  organizational assessment; management training; ongoing coaching of task groups; and extensive one-on-one coaching of facility leaders. He analyzes and develops leadership effectiveness and efficiency in work processes, focusing on assessing an organization’s preparedness for a survey, evaluating processes in achieving preparedness, and guiding organizations toward compliance. 

As a presenter at national seminars, regional conferences, and audio conferences, Brad teaches the Keyes Life Safety Boot Camp series to various groups and organizations. He is the author or co-author of many HCPro books, including the best-selling  Analyzing the Hospital Life Safety Survey, now in its 3rd edition. Brad has also authored a variety of articles in numerous publications addressing features of life safety and fire protection, as well as white papers and articles on the Building Maintenance Program. Currently serving as the contributing editor of the monthly HCPro newsletter Healthcare Life Safety Compliance  gives Brad further insight into the industry’s trends and best practices.