Fire doors, drills, and the ED; Joint Commission clarifies Life Safety Code requirements

Briefings on Accreditation and Quality, August 22, 2017

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In May, The Joint Commission issued clarifications on its 2012 Life Safety Code® (LSC)–related requirements for fire doors, fire drills, and emergency department (ED) occupancy. Here’s a look at the four clarifications and what they mean.

1.    ED occupancy classifications

Certain EDs have to follow LSC requirements for either a healthcare occupancy or ambulatory healthcare occupancy depending on how long they let patients stay and how self-sufficient those patients are.

“The clarification with the greatest financial impact concerns ED occupancy classification, especially for freestanding EDs,” wrote George Mills, MBA, FASHE, CEM, CHFM, CHSP, Joint Commission director of engineering, in a blog post. “Generally, freestanding EDs have been identified as ambulatory occupancies. However, earlier this year, an external communication identified EDs as healthcare occupancies, based on patient care in EDs that appeared to exceed the 24-hour stay that defines ambulatory.”

In short, at a minimum all EDs are considered ambulatory occupancies. However, an ED is considered to be a healthcare occupancy if it provides:

•    Sleeping accommodations for people incapable of self-preservation
•    24-hour housing

For additional clarity, Mills recommends reading the 2012 LSC to decide if an ED counts as an ambulatory or a healthcare occupancy.

Steve MacArthur, a safety consultant at The Greeley Company in Danvers, Massachusetts, says not all EDs are configured the same, either physically or operationally. That’s why EDs don’t have a single-occupancy classification under NPFA regulations.

“For example, if there’s only one trauma room, then you might be able to hold the line at an ambulatory occupancy,” MacArthur says. “But if you have more than three trauma rooms, it will be tough to defend anything less than a healthcare occupancy designation. Some smaller facilities don’t have any trauma rooms, so they might be able to demonstrate that they can run with a business occupancy designation.”

The effect on hospitals and clinics will depend on what their EDs were originally labeled as. For example, if an ED is changing from a business occupancy to an ambulatory occupancy, it has some work to do.

 “Business occupancies are only required to do annual fire drills, so that would have to increase to quarterly drills,” MacArthur says. “Though [the drills] wouldn’t necessarily have to be in the ED; they could just fold them into the rest of the hospital. Also, egress widths are a little more unforgiving, unless they configure the space as a non-sleeping suite, which may require construction of barrier walls, etc.”

In addition, an ED’s new occupancy might mean it has to follow Interim Life Safety Measures (ILSM) to compensate for the LSC deficiencies that may exist as the result of the reclassification.

“For organization that have always maintained their EDs as straight healthcare or ambulatory healthcare occupancies, this will have little or no impact,” notes MacArthur. “Unless those with ambulatory designations are holding patients overnight, in which case they might have some explaining to do.” 

2.    Annual door inspections

 Fire and smoke doors are required to have annual inspection and testing. This year’s testing must have been completed before July 5, 2017.

This applies to door assemblies that:

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