Delayed Egress Locks

Q: Lately, due to many different construction projects within this hospital, contractors install crash bars (aka panic bars) on doors that have locks for security reasons. The doors do lead to alternate evacuation exits/stairs. The crash bars release the locks in 15 seconds and I have been told that signs notifying people of this is required on the doors. Where is the code for this requirement? One location is an entrance directly into an outpatient care service directly off the public elevator lobby. At two newer locations on another floor, employees are to use their ID badge for access but in one location the sensor is not readily seen. In this location employees frequently open the door via the crash bar setting off the alarm requiring someone to go there to reset the alarm. The message contractors are putting on the doors read: PUSH UNTIL ALARM SOUNDS / DOOR CAN BE OPENED IN 15 SECONDS. The message gives people permission as well as instruction of how to enter a secured area. Where is this code requiring the sign and does it specify the message?

A: Yes… The answer to your question is: Section 7.2.1.6.1 of the 2012 Life Safety Code.

What you have on these doors are called “Delayed Egress Locks”, and the sign that reads “PUSH UNTIL ALARM SOUNDS – DOOR CAN BE OPENED IN 15 SECONDS” is a requirement. If you don’t have these signs, you can be cited by an inspector or surveyor.

Also, as an FYI… you are not allowed to use delayed egress locks on doors in the required path of egress unless the facility is fully smoke detected or fully sprinklered. So, check with your staff to determine if your building is fully sprinklered. In all my 40+  years in this business, I have never seen a fully smoke-detected hospital.

Keep in mind, delayed egress locks are not designed to secure an area. They are designed to allow access through the door on a delayed basis. If the door is located in the required path of egress, then you cannot secure the door, unless it meets one of the exceptions provided in section 19.2.2.2.4.

Heated Massaging Seat

Q: I work at an ICF facility. We have a person with arthritis and I was just asked if a heated pad massaging seat could be purchased for them. I know we can’t have heated blankets, personal heaters, etc. With this item having heat, I would assume it would probably not be approved either. Can I get your input??

A: There are no CMS codes or standards that would prohibit this type of device. Actually, there are no codes or standards that would prohibit electric heating blankets, but the perceived risk of danger usually disqualifies them from use.

There will be risks in using this heated, massaging seat that you need to address, such as:

  • Trip hazard with the electrical cord
  • Something heavy rolling on the electrical cord creating a pinch-point, thereby causing a short-circuit over time
  • The seat becoming too hot for the patient

If you address these risks in a risk assessment and mitigate them to the satisfaction of the surveyor, you should be fine.

Emergency Management

Q: Regarding the new CMS rule on emergency preparedness, are they telling us that we must have full heating and cooling support for the entire hospital during a power outage up to and including adding more generators?

A: No… I don’t believe it is. Section 482.15 (b)(1)(ii)(A) says, “The hospital must develop and implement emergency preparedness policies and procedures … that must address temperatures to protect patient health and safety”. This does not say or mean that you need to add equipment to maintain temperatures (other than what the Life Safety code and NFPA 99 requires). It’s saying you must have a policy and a procedure that must address temperatures to protect the health and safety of patients.

So, your policies must reflect a plan on how you are going to accomplish this. If you lose fuel for the heating appliances, then what is your back-up plan? If you lose normal power and then emergency power, what is your back-up plan? Ultimately, your plan should recognize that you must evacuate the building if you can no longer maintain safe temperatures for your patients and staff.

Magnetic Locks

Q: Is there a code requirement for testing magnetic-locking devices, for a facility maintenance director?

A: There is a requirement in NFPA 72-2010, section 14.4.5 that all interface devices (i.e. relays, control modules) be tested once per year. Since the magnetic locks in access-control and delayed egress locks are connected to the fire alarm system via an interface relay, then the magnetic lock needs to be tested once per year to ensure it disconnects during a fire alarm signal. This test is required to be conducted by someone who is certified in accordance with NFPA 72.

If you are CMS certified or accredited by any of the major accreditation organizations then you would be expected to comply with the manufacturer’s recommendations on preventive maintenance. Most manufacturers of magnetic locks requires periodic maintenance to ensure they are functioning correctly.

Temporary Emergency Power Generators

Q: We are going to have temporary generators onsite for two months that we will use during our construction project to replace the main power distribution gear for our bed tower, installing new substation and distribution gear. During the time we will have 10 shutdowns from 4 hours to 12 hours at a time. We will be on the regular emergency power generators and ATS’s normally and only on the temporary units for the shutdowns. This affects normal critical and life safety circuits. Do we have to do monthly generator, and ATS transfers on the temporary units or would the shut downs count for testing? And for annunciation, we are planning to have the generators manned anytime they are in operation with no other temporary remote annunciation. Is this permissible?

A: These are all good questions, and I can provide you with answers on how I would approach this, but ultimately you need to talk with your state, local, and accreditation AHJs in order to get their opinions. Their opinions count and mine does not.

But since you asked, the accreditation organizations already allow an actual emergency event when the generators operate to count as one of the monthly load tests, provided the emergency event meets all of the requirements for a monthly load test. Therefore, I do not see any difference if the temporary generators operate or the regular emergency generators operate during an emergency event. So, I would say you still need to conduct monthly load tests on the generators (normal and temporary units), but an emergency event can count as one of the monthly load tests if it meets all of the requirements for a monthly load test.

I would think an ILSM on the annunciation issue should be sufficient, rather than running a temporary annunciation panel.

Strange Observations – Sprinkler Pipe Supported From Ductwork

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

This is another picture of sprinkler pipe supported from HVAC ductwork, similar to last week’s Strange Observations.

I include it here to emphasize that sprinkler pipe cannot be supported from anything except the building structure itself.

I suspect I see this problem in 75% of the hospital where I consult… but then, I’m looking for it.

There is one exception to that rule… Sprinkler pipe may be suspended from a hanger that also supports ductwork, provided the hanger is designed to support the weight of the duct, the pipe, the water in the pipe, and an additional 250 lbs. (see NFPA 13-2010, 9.2.1.5). If you ever see sprinkler pipe suspended from the same hanger that supports ductwork, ask the installer to provide documentation that the hanger can support that weight.

Probe Cleaning Room

Q: We have two small processing rooms in a hospital where they clean and reprocess vaginal probes, using the chemical RESERT. Should these rooms be held to the same standard as an Endoscope cleaning room (negative pressure, 10 ACH and exhausted directly to the outdoors, per FGI Guidelines)?

A: I would think so… The Life Safety Code does not comment on this, so it ends up being an issue that the Infection Control people should be consulted. Also, since it is a design issue, please check with your state and local authorities to see if they have a comment.

Portable Space Heaters

Q: Could you please clear up a concern related to section 19.7.8 of the 2012 Life Safety Code, that addresses Portable Space-Heating Devices? Section 19.7.8 (1) states such devices are used only in non-sleeping staff and employee areas. Does this mean that the approved space heaters are allowed at nurse stations or offices that are located in the same smoke compartment as patient care rooms?

A: It really depends on the AHJ’s interpretation of the term “non-sleeping staff and employee areas”. I know Joint Commission interprets this to mean approved space heaters cannot be used in any smoke compartment that contains patient sleeping or treatment activities. Other AHJ’s may not be as definitive, and leave it up to the surveyor to decide.

Personally, I suggest you go with Joint Commission interpretation (see LS.02.01.70, EP 8) as that seems to me to be the more restrictive. You should be safe with most other AHJs if you follow that interpretation.

Handrails

Q: According to the 2012 Life Safety Code, section 7.2.2.3.5, the distance between a handrail and adjoining wall should be 2¼-inches. Does this apply to just spaces in which NFPA requires handrails such as stair and ramps, or does it apply to corridors where a handrail is not specifically required by NFPA? If so, then in areas where NFPA does not require a handrail, but one is installed such as in a corridor, can the distance between the handrail and the wall just have to comply with ADA and the building code, which is 1½-inches?

A: Section 7.2.2.4.4.5 of the 2012 LSC does require new installation of handrails on stairs and ramps to be at least 2¼ inches from the wall. Since section 7.2.2.4.5 is a sub-section of 7.2.2 “Stairs”, this 2¼ inch requirement is limited to just stairs and ramps. It does not apply to handrails on corridors.

I do not see any restrictions on clearance between a handrail and the wall in corridors, other than the CMS limitation of 4-inches maximum projection into the corridor.

Strange Observations – Sprinkler Pipe Suspended From Ductwork

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

Some organizations fail to install sprinklers underneath the ductwork that is 48-inches wide or wider. This facility did not forget, but the sprinkler-fitter who installed this pipe for the sprinkler head attached it to the ductwork, which is not permitted.

The sprinkler pipe can only be suspended from the building itself (i.e. structural beams, joists, etc.), and not from anything else.

There is one exception to that rule… Sprinkler pipe may be suspended from a hanger that also supports ductwork, provided the hanger is designed to support the weight of the duct, the pipe, the water in the pipe, and an additional 250 lbs. (see NFPA 13-2010, 9.2.1.5). If you ever see sprinkler pipe suspended from the same hanger that supports ductwork, ask the installer to provide documentation that the hanger can support that weight.

Staff Sleep Rooms

Q: In regards to audio/visual strobes in staff sleeping rooms, is it required for them to hear the fire alarm system?

A: According to section 26.3.4.5.1 of the 2012 Life Safety Code, single-station smoke alarms are required to be installed in sleeping rooms for lodging or rooming house occupancies. A staff sleeping room in a hospital would have to qualify for the requirements of a lodging or rooming house occupancy, so a single station smoke alarm is required.

A single station smoke alarm has a built-in occupant notification device. But section 9.6.2.10.1.4 of the 2012 Life Safety Code says fire alarm system smoke detectors that comply with NFPA 72 and are arranged to function in the same manner as a single-station smoke alarm shall be permitted in lieu of smoke alarms. Even if you install a fire alarm system smoke detector in the staff sleeping room, section 9.6.2.10.1.4 would imply that some sort of occupant notification device is still required to awaken the staff member sleeping in that room.

But section 18.4.4 of the NFPA 72-2010, allows for the Private Mode installation for fire alarm system occupant notification devices, and hospitals typically are designed to this requirement. Section 18.4.4.1 requires the occupant notification device to have an audible sound level 10 dB above the average ambient sound level to be compliant, and in many cases, an occupant notification device located in the corridor outside of the staff sleeping room can achieve this requirement.

If you measure the dB level inside the staff sleeping room of the corridor-mounted fire alarm system occupant notification device, and it is 10 dB above the average ambient sound level in the staff sleeping room, then you should be good. But have those sound readings available to show the surveyor, as they will want to see some proof of compliance.

Fire Extinguishers

Q: At our hospital there is some question about which type of portable fire extinguisher should be installed in our operating rooms. We can’t find an actual requirement for this and would appreciate your opinion.

A: I don’t think you will find anything in the NFPA codes and standards that recommends a type of fire extinguisher to be used in an operating room. To be sure, section 9.7.4.1 of the 2012 LSC says portable fire extinguishers must be selected, installed, inspected, and maintained in accordance with NFPA 10.

Section 5.1 of NFPA 10-2010 says the selection of fire extinguishers for a given situation shall be determined by the following factors:

(1) Type of fire most likely to occur

(2) Size of fire most likely to occur

(3) Hazards in the area where the fire is most likely to occur

(4) Energized electrical equipment in the vicinity of the fire

(5) Ambient temperature conditions

So, what types of fires are likely to occur in an operating room? I would say Type A fires (fires involving combustibles like paper, plastic, cardboard, linen); and Type B fires (fires involving combustible and flammable liquids, like skin prep alcohol); and Type C fires (fires started by electrical means). I don’t believe Class D fires (combustible metals) and Class K fires (cooking oils) are very likely in an operating room. 🙂

So, you need portable fire extinguishers that will cover ABC fires, but the most common ABC extinguisher is a dry powder and is not suitable to be used in an operating room. So, you could use a CO2 type extinguisher which could handle BC fires, as the CO2 is a clean agent that would not do any residual harm to the patient. But what to do about Class A fires? Most surgical procedures have sterile water in a basin in the sterile field of the surgery. You can teach the staff to use the sterile water on any Class A fire involving the patient or nearby.

Keep in mind, there is no requirement that you have to have portable fire extinguishers in the operating room. All you need is to meet the maximum travel distance to get to a fire extinguisher. You could place a Class BC extinguisher out in the corridor outside the operating room, which would be fine as long as you do not exceed the travel distance to get to a Class B extinguisher, which is 35 feet for a 5-lb. unit and 50 feet for a 10-lb. unit.

Fire Extinguishers

Q: Do fire extinguishers that are placed in patient care areas of a hospital have to be placed in a wall cabinet, or can they hang from the wall?

A: NFPA 10-2010 does not require extinguishers to be mounted in a wall-cabinet. They are permitted to be mounted on a wall without the use of a cabinet. But be aware that CMS limits all wall projections into the corridor to be no more than 4 inches, which the average 10-lb. extinguisher would exceed.

Consider the Oval brand of fire extinguishers, as they project less than 4 inches.

Duct Detectors

Q: With regard to testing duct detectors in a hospital, I understand that on an annual basis the automatic shutdown of the AHU’s must be verified when duct detectors are activated. I am unclear if there is also an annual requirement to verify damper (pneumatic and/or electric type but excluding fused links) operation at the same time. Also, is there a requirement to test smoke dampers annually?

A: No… there is not. Even though NFPA 72-2010 does require confirmation of all interface relays tested on an annual basis, and does imply that actuation of the dampers are required, NFPA 72-2010 cannot regulate the testing of fire or smoke dampers. Only NFPA 80-2010 and NFPA 105-2010 can regulate testing requirements for fire and smoke dampers respectfully.

You still have to test the interface relays (modules) on an annual basis, but you are not required to confirm that the smoke dampers did close on an annual basis.

But be aware, that some surveyors may require that you do confirm the smoke dampers closed on an annual interface relay test… That would be an incorrect interpretation on their part, and you may want to point out that NFPA 4 was created (in part) to eliminate these conflicting cross-testing requirements.

Emergency Power Generators

Q: I am a consultant and I visited an ASC that had a natural gas generator housed indoors, located in the basement of the facility. The ATS switch was located in the same room as the generator. I am not used to seeing generators located inside of the building. Is the ATS allowed to be in the same room? Also, there was no emergency battery backup light at the location of the generator and there was no emergency stop button located anywhere in or outside of the facility. Isn’t this required?

A: The fact that the generator is located inside the building may be acceptable, depending when the generator was installed. NFPA 110-2010, section 7.2.1 says the generator shall be installed in a separate room and emergency power supply system equipment shall be permitted to be installed in this room. So, this allows the generator to be installed inside the building in a room, and this allows the ATS to be mounted in the same room.

According to section 7.2.1.1 the room must be separated from the rest of the building by 2-hour fire rated barriers, or the generator may be located outdoors. So, when you see generators mounted inside in a room, check the entrance door (if the door connects the room to the rest of the building) rating as it must be 90-minute fire rated, and the walls must be 2-hour fire rated without any unsealed penetrations.

According to section 7.2.1.2 nothing else, other than what has been described, may be permitted in this room. So the room cannot be used to store ladders, equipment, supplies, etc.

According to section 7.2.3, the room housing the generator must be designed and located to minimize the damage from flooding, caused by fire-fighter flooding; sewer backup; natural disaster. So, locating a generator in a basement does not seem to fit this requirement. This requirement was also found in the 1999 edition of NFPA 110, which was required to be complied with by CMS since March 11, 2003. So, if this generator was installed since March 11, 2003, I would say it is subject to a finding by a surveyor for not locating the generator in an area that would not be affected by flooding.

According to section 7.3.1, the generator equipment location must be provided with a battery-powered emergency lighting. So, if there is no battery powered emergency lighting unit, then that is a potential finding by a surveyor.

According to section 5.6.5.6 the generator must have a remote manual stop station located outside the room that houses the generator, and the remote manual stop station needs to be labeled. So, again, if there is no remote stop switch, then that is another potential finding by a surveyor.