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Electrical power strips: Howthey are regulated by the Life Safety Code

Fri, 01 Jun 2012 04:00:00 GMT

Electrical power strips: How they are regulated by the Life Safety Code

The use of electrical power strips in healthcare settings is a great concern to facility managers and surveyors alike since the applicable NFPA codes and standards do not clearly address their use. As a result, safety professionals and authorities having jurisdiction are often confused about whether a given type of power strip is acceptable.

However, it may be helpful to realize that the 2000 edition of the Life Safety Code® (LSC) does provide guidance on all issues electrical, and power strips in general. For new construction, section 18.5.1 refers to section 9.1, which requires compliance with NFPA 70, National Electrical Code (1999 edition). Section 18.5.1 also requires compliance with NFPA 99, Health Care Facilities (1999 edition). For existing conditions, section 19.5.1 also refers to section 9.1, which points the reader to NFPA 70.

Power strips are temporary wiring devices by definition, and NFPA 70 (1999 edition) article 305-6 discusses temporary wiring that is used to provide power for temporary equipment. While this section primarily addresses extension cords, power strips fall into this general category.

In addition, NFPA 99 (1999 edition), section 7-5.1.2.6 says extension and power cords must be "adequate for the application" and must meet the requirements of section 9-2.1.2.2, which has general requirements, but also says they must be a suitable type for the application. So, while the code and standards do not specifically regulate power strips, they provide the general requirement that they must be adequate or suitable for the application.

How does one go about selecting the appropriate power strips when the codes and standards do not specify the proper types? One hospital found a new way after undergoing a CMS validation survey.

Mark Addis, director of biomedical engineering at San Francisco General Hospital, said that instead of performing a tracer, the surveyors first went to the administrative offices, which was very surprising. Addis spoke during the March 27 Grainger Healthcare On the Job webinar/audio conference.

"They immediately began writing citations wherever they found power extension cords or power strips," said Addis. "The power strips connected to computers did not have surge protection."

According to Addis, CMS was citing NFPA 70 (1999) article 220, which is primarily a standard on branch circuit, feeder, and service load calculations and computations. All told, CMS cited the hospital for more than 100 deficiencies involving improper use of extension cords and power strips.

"They were also giving us deficiencies for what was plugged into the power strips, such as microwave ovens, permanently fixed equipment, floor heaters, and fans. These items are not allowed to be plugged into temporary wiring devices, and power strips are temporary wiring devices," said Addis. "You are only allowed to plug these items in for a temporary point of time, even though it is not stated what that frame is."

Not having enough outlets in rooms and common areas was not a new revelation for Addis. Prior to the CMS validation survey, he knew the hospital had a problem with power strips, but was powerless to resolve it.

"One clinic room was also shared as a nurse's locker room. During a routine inspection we found three six-outlet power strips daisy-chained together; one end plugged into the wall outlet and the other outlet end led to a locked locker. The nurse manager unlocked it for us, and we found that someone had a pot of coffee in the locker," said Addis. "The CMS surveyor did not see that particular problem, but they did find many daisy-chained power strips." Daisy-chained refers to one power strip being plugged into another power strip, which is not allowed for temporary wiring devices.

That said, power strips were not the only electrical issues that were cited during this CMS validation survey.

"One surveyor found burn marks on electrical outlets in our behavioral health unit. He asked a staff member how the electrical outlet received the burn marks, and the answer took everyone by surprise. He was told patients insert metal objects into the outlets to create an electrical short or spark, and they light tea bags in order to smoke them," said Addis. "The CMS surveyors were going very deep into electrical issues by interviewing staff and writing us up not only on the misuse of power strips, but also for the abuse of electrical power in the hospital."

Following the CMS validation survey, Addis and his staff were required to develop a plan for how the hospital was going to correct these problems. They researched what the codes and standards required for power strips and found little direction other than the phrase "must be suitable for the application." Addis then turned his attention to Underwriters Laboratories (UL) standards and listings and found that not all hospital-grade power strips are the same. He selected four different power strips, each with a different UL listing, that could be used in various applications in the hospital.

"UL 60601-1 is my favorite one. This is actually listed as a medical device and not a power strip. This one was very key in our Plan of Correction for CMS as it is allowed within the 6-foot patient ring," said Addis.

The 6-foot patient ring that Addis refers to is the vicinity intended for patient examination, treatment, and recovery, which extends 6 feet beyond the normal location of the bed, chair, table, treadmill, or other device that supports the patient during examination and treatment. This patient care vicinity extends 7½ feet above the floor.

"The UL 60601-1 cannot be mounted to any particular device according to the UL standards, but we do Velcro them to the wall. It is not permitted to require the use of a tool to remove this device, and they are permitted to be placed on the floor," said Addis. "We limit the UL 60601-1 devices to four outlets rather than six, as we found six outlets on one circuit can be enough to trip the breaker."

One other peculiarity of the UL 60601-1, according to Addis, is it actually looks for a ground to ensure its integrity. Therefore, this device will not work where isolated power systems are in use.

"The UL 1363 is the one I purchased for operating rooms and works very well with isolated power systems," said Addis. "It can also be used inside the 6-foot patient ring."

Another device, UL 1363-A, has a similar identifying number, but is allowed to be used on mobile carts, such as crash carts, IV poles, anesthesia machines, and ventilators, according to Addis. It is only intended to be used for the equipment associated with that particular cart.

The final device Addis and his staff selected was the UL 1449, which has built-in surge suppression. These devices were selected for the office environment. The question was posed to Addis: Why not use office-grade power strips since hospital-grade is not required for this environment?

"We figured that once we provided these devices, they probably won't stay where we placed them. Our concern was these devices could migrate out and have hospital equipment plugged into them. We wanted to make sure our patients were safe and protected from electrical shock," said Addis. "Some of these office-grade devices do not have any surge protection and only come with an on/off switch and no circuit protection devices."

Addis explained that the hospital decided it was not enough to have a policy regarding which power strip could be used in what specific areas-it also needed to regulate the distribution of these devices as well.

It was decided that no department would be permitted to purchase power strips; instead, biomedical engineering and facilities engineering would distribute the appropriate devices to the departments. This decision was well received by the departments as they did not have to dip into their own budgets to obtain the devices.

"We provide the three [UL 60601-1, UL 1363, and UL 1363-A] used in the 6-foot patient ring, and facilities engineering provides the UL 1449 for the office environment," said Addis. "The three issued by biomedical engineering receive identification tags, and the UL 60601-1 receives PM tags and is inspected once every three years since it is considered a medical device.

"I actually welcomed the over 100 citations that we received from CMS because before the survey I had little control over the problem. But once we were cited, the CEO was on our side in resolving this problem and funds became immediately available. We currently have over 1,200 power strips on inventory between biomedical and facilities engineering," said Addis.

Members of the hospital's Environment of Care committee perform routine hazardous inspections, which now includes inspecting for the appropriate power strip. When they identify problems, they provide on-the-spot education for the staff and managers on the proper use of power strips.

This has gone a long way toward creating a safe environment, and there is no longer any concern about using the incorrect power strip.

Managing electronically monitored fire extinguishers

Fri, 01 Jun 2012 04:00:00 GMT

Managing electronically monitored fire extinguishers

Consider this scenario: A fire develops in a utility room and a nurse runs to the nearest fire extinguisher location, only to find the extinguisher is missing. She then proceeds to another location, grabs the extinguisher there, and races back to the utility room, where she properly uses the extinguisher to put out the fire. Where was the missing extinguisher? Who knows-it could have been removed for quite a few reasons, including maintenance or theft.

This is a very real scenario, and it may end tragically if the staff member cannot find an alternative extinguisher, giving the fire time to grow out of control. To circumvent this problem, more than one company has cashed in on developing an electronic monitoring system, an increasingly popular option.

One of the newer devices on the market is an electronic system to monitor each fire extinguisher for certain functions. The system will trigger an alert in the following circumstances:

An extinguisher is removed from its mounting bracket
The pressure inside an extinguisher's cylinder drops
Something is placed in front of an extinguisher, blocking access to it

There are multiple companies offering basically the same type of electronic monitoring product; all versions of the product attach directly to the extinguisher cylinder and include sensors to detect when something is placed in front of the extinguisher.

The system's ability to detect objects obstructing the extinguisher is a unique advantage, although it should be noted that the system will wait a couple of hours to report the problem in case the obstruction is of a temporary nature.

To track whether the extinguish is still in its bracket, a special tether switch is connected to the extinguisher; as soon as the extinguisher is removed from the bracket, a switch is activated and a signal is immediately sent through the fire alarm system.

Finally, the pressure of the cylinder is electronically monitored using a special pressure gauge that sends an electronic signal when the pressure drops below an acceptable level.

As mentioned, the electronic signals are transmitted through the automatic fire alarm system, and when one of the sensors activates, the signal can be directed to supervisory personnel rather than sounding a facilitywide alarm.

At least one manufacturer has been working behind the scenes with code-writing authorities and those authorities who enforce the codes, also called authorities having jurisdiction (AHJ). Through their efforts, they have succeeded in modifying the monthly inspection requirements found in NFPA 10, Standard for Portable Fire Extinguishers (2010 edition). The new edition will allow monthly inspections or continuous electronic monitoring to check the following:

Extinguisher located in designated place
No obstructions to access
Pressure in the operable range
Fullness as determined by hefting the extinguisher
Condition of tires for wheeled extinguishers
Indicator for nonrechargeable extinguishers using a push-to-test pressure indicator

The electronic monitoring systems can achieve all of the above items, with the exception of checking the condition of the tires and the push-to-test buttons on nonrechargeable extinguishers. However, not many hospitals use wheeled or rechargeable fire extinguishers.

Having achieved a change in the monthly inspection requirements for the 2010 edition of the standard is significant, as the 1998 edition-the current edition for those of us required to comply with the 2000 edition of the Life Safety Code® (LSC)-has additional requirements that the electronic monitoring system cannot achieve. Those are:

Verifying that operating instructions on nameplates are legible and face outward
Checking for broken or missing safety seals and tamper indicators
Examining for obvious physical damage, corrosion, leakage, or clogged nozzle

So, you may ask, did NFPA simply drop those requirements for the 2012 edition? Well, in a way, yes, but not for all extinguishers. It will only require the above three features to be inspected on a monthly basis for extinguishers with any of the following conditions:

High frequency of fires in the past
Severe hazards
Locations that make them susceptible to mechanical injury or physical damage
Exposure to abnormal temperatures or corrosive atmospheres

So extinguishers in most areas of a typical hospital would not be mandated to meet the additional requirements, and the electronic monitoring system would be acceptable. Of course, NFPA did not readily explain how many fires constitute a high frequency of fires, or what qualifies as a severe hazard. Those determinations are left up to the individual AHJ.

One of the manufacturers of the electronic monitoring system has already consulted The Joint Commission and received unofficial approval of its system. The agency made it very clear that it does not endorse any products, but it did acknowledge that the electronic monitoring system appears to exceed the requirements of its EC.02.03.05, Element of Performance 15, standard for monthly fire extinguisher inspection, and it is willing to accept this technology. Its reasoning is based on LSC sections 1.5.1 and 1.5.2, which allow equivalent systems to be deemed acceptable. What is not clear is how The Joint Commission finds the electronic monitoring systems to be equivalent to NFPA 10 (1998 edition) requirements for verifying that the operating instructions are legible and face outward, that safety seals are not broken or missing, and that the extinguisher does not show signs of corrosion, damage, leakage, or a blocked nozzle. The electronic monitoring system does not perform these tasks, yet the Joint Commission standard refers to NFPA 10 (1998 edition) for guidance.

It's important to remember that the typical hospital has five or six different AHJs that it must comply with, and all of them enforce either the LSC or some similar document. The Joint Commission is just one of those authorities, and just because one AHJ sees the electronic monitoring system as being equivalent does not mean the others will.

What does CMS say about this product? When asked, an official at one manufacturer said they have tried to get an answer, but so far CMS is not saying whether it believes the product is equivalent. No mention was made of the many state fire marshals and department of public health officials who likewise have a say in hospital safety. One thing is clear: Once CMS adopts the 2012 edition of the LSC, the 2010 edition of NFPA 10 will also be adopted, rendering these issues obsolete. Perhaps CMS is simply waiting to adopt the 2012 edition rather than making a special decision on the electronic monitoring system.

The concerns over meeting the requirements of the 1998 edition of NFPA 10 have not deterred many organizations from installing the electronic monitoring systems in their hospitals and medical buildings, or attempting to get the systems installed. The cost savings from using the system versus having an individual perform the monthly inspections is significant, although the initial costs can be quite steep. One facility manager in a Midwest hospital, who wished to remain anonymous, said it would cost $250,000 to install the system, and he could not get the project approved through the capital review board.

One of the manufacturers offers another product that utilizes the same technology in a different way. It is a device that is designed to be incorporated with the oxygen tank regulator and tracks the cylinders throughout the hospital using the wireless technology already in place. In addition to tracking where the oxygen cylinders are located, the device monitors the pressure in the cylinders, which ultimately provides a safer environment for the patients.

Understanding path of egress in a construction zone

Fri, 01 Jun 2012 04:00:00 GMT

Understanding path of egress in a construction zone

One of the most common problems with construction in an occupied hospital is how to arrange safe passage to an exit in the event of a fire. Facility managers, project leaders, and safety officers often struggle with this issue whenever the topic of renovation or remodeling comes up. While there should always be at least two paths of egress for all areas of the hospital, there may be times when one of those paths becomes impaired due to some function of the construction.

The path of egress in a construction zone may have to serve multiple purposes, the first being obvious: egress for the workers in the construction area to leave the zone. But at times, the organization may find itself in a situation where an emergency path of egress into the construction zone must be maintained for occupants in a neighboring part of the hospital. While it is never ideal to exit patients or staff into a construction zone to get to a secondary emergency exit, there are circumstances in which this is a necessity.

Consider a specialty nursing unit that is located on an upper floor, at the end of an addition or wing. A renovation project is planned that will compromise the path of egress to a stairwell at the far end of the wing. Administration will not allow the specialty unit to be shut down or relocated during the renovation. This scenario happens nearly every day in hospitals across the country, and the hospital project team worries about exiting. They know they need two paths of egress from any spot in the hospital, but how do they provide a legal path to the stairwell when it will be compromised by the construction?

The answer is: You don't provide a legal path of egress to that exit stairwell at the far end of the unit, but you do provide the best path of egress that you can. That is why the Life Safety Code® (LSC) has a section on alternative life safety measures (ALSM), or interim life safety measures as some authorities having jurisdiction (AHJ) call them. The AHJs understand that in order to make an omelet, you have to break a few eggs. Likewise, renovation and remodeling at times will impair some features of life safety during the construction process. As part of the Pre-Construction Risk Assessment (PCRA) process, the evaluation on how the construction will impact exiting is one of the assessments involved.

To be sure, you never want to place patients or staff in harm's way, but construction activities may dictate an exit access corridor that may be less than what the LSC requires. The exit access corridor itself is the major player in the path of egress. If there is no other way to do the construction other than to set up temporary construction barriers that infringe on the required width of the corridor, then that's what you have to do. The PCRA will identify that the corridor width will be reduced in a particular area, and the ALSM will identify what alternative measures will be implemented to compensate for the life safety deficiency.

Corridor width is not the only issue that the project team needs to be concerned with:

The interior finish in the exit access corridor is required to be Class A or Class B, which means the flame spread rating of the walls and ceiling cannot exceed 75.
The headroom in the path of egress is required to be no less than 7 feet 6 inches, with projections from the ceiling not less than 6 feet 8 inches above the floor.
The walking surface cannot have an abrupt change in elevation of more than ¼ inch.
Nothing is allowed to obstruct access to the exit or the visibility thereof.
The corridor itself is required to be separated from all other areas of the facility with 30-minute fire-rated barriers that extend from the floor to the deck above, and openings may be equipped with non-rated smoke-resistant, positive-latching doors if the smoke compartment is not protected with sprinklers.
The corridor barriers may be non-rated and resist the passage of smoke and extend from the floor to the ceiling, provided the ceiling also resists the passage of smoke, and openings may be equipped with non-rated smoke-resistant, positive-latching doors if the smoke compartment is protected with automatic sprinklers.
The ceiling is required to resist the passage of smoke if equipped with fire alarm smoke or heat detectors; sprinkler heads; or if the corridor separation barriers are smoke resistant and do not extend any farther than from the floor to the ceiling.
Illumination of the path of egress is required to be maintained to be at least 1 foot-candle as measured at the floor.
Markings of the path of egress are required with appropriately located "Exit" signs.
Temporary construction barriers must be one-hour fire rated with appropriately rated doors if the construction area is not protected with automatic sprinklers. Note: Some AHJs permit fire-retardant plastic visqueen in lieu of fire-rated barriers.

The above requirements are mandatory in order to be in compliance with the LSC. However, as previously mentioned, total compliance is not always possible during renovation and construction. Therefore, the PCRA needs to assess the potential construction project to determine whether any of the above requirements cannot be maintained during the course of activities. If the answer is no, then a risk assessment should be conducted to determine whether it would be permissible to evacuate patients and staff through the construction zone in the event of an emergency. This is a decision that the hospital should make with input from a variety of individuals and departments, such as infection control, risk management, chief nurse, nurse manager, safety officer, security manager, facility manager, and project manager.

If the risk assessment concludes that the impaired path of egress into the construction zone is permissible for use as a secondary exit, an ALSM must be conducted, with the results properly documented. Alternative measures must be implemented to compensate for the LSC deficiencies and continued as long as the deficiency remains.

A hospital operation can never be without some level of risk. The intent of safety professionals is to minimize that risk as much as possible. The standard risk assessment is a very effective tool to use when the codes or standards are not clear on what path to take. A simple approach is to take a piece of paper, draw a vertical line down the middle, and list all of the advantages of the option on the left, and all of the disadvantages of the option on the right. The side with the most items listed, or the most significant items, "wins." The risk assessment should be conducted with multiple individuals who have some interest at stake in the matter. After the conclusion of the risk assessment, it is strongly recommended that the results be submitted to the organization's safety committee for review and approval, and the results entered into the committee's minutes. That way, if challenged by a surveyor, the organization can demonstrate that an appropriate risk assessment was performed.

Once the ALSMs have been implemented, make sure they are reinforced frequently. If daily activities such as inspections, removal of combustibles, and exit access monitoring are required, make sure you have a designated individual performing and documenting those activities. While no affront to contractors is intended, it is recommended that you do not rely on them for this important safety function. They frequently do not have the knowledge and expertise regarding hospital fire safety that a hospital employee would have. Also, although some AHJs have permitted it, it is not recommended that you ask staff members working in the general vicinity to carry out any of these responsibilities. They have enough to do without shouldering the burden for something they may not be familiar with.

It is best practice to make the project manager responsible for these daily ALSM activities. He or she needs to be on the scene where the project is under way, meeting with contractors and watching for possible errors and omissions. This person can perform the daily inspections that the ALSM requires at that time.

To be sure, exiting into a construction zone to get to an exit is not desirable, but at times, it may be the only option that you have.

Extension Surveys: A little-known piece of accreditationcompliance

Fri, 01 Jun 2012 04:00:00 GMT

Extension Surveys: A little-known piece of accreditation compliance

If your healthcare organization acquires a new service, program, or site for which The Joint Commission has standards, you might be in for a surprise survey by a Life Safety Code® (LSC) specialist surveyor. All right, it isn't really a surprise; The Joint Commission actually says it will do this in the Accreditation Process chapter of its Hospital Accreditation Standards manual. But really, outside of the accreditation manager for your organization, who actually reads this chapter? Well, I suggest you take a peek at it to be familiar with the "Extension Survey," as The Joint Commission calls it.

The Extension Survey also applies to current programs, treatments, and services if there is significant alteration by your organization. Normally, the way The Joint Commission finds out about these alterations or acquisitions is by notification from the healthcare organizations themselves. But if your organization has difficulty communicating these details to the individual in charge of LSC compliance, an Extension Survey may come as a surprise.

The Joint Commission explains that the Extension Survey is conducted to ensure that the accreditation decision previously awarded to the hospital is still appropriate under the new conditions. If the hospital does not use Joint Commission accreditation for deemed status (meaning it does not receive reimbursements for Medicare and Medicaid services), then the Extension Survey findings are maintained separately from the regular triennial survey findings and are not rolled together until 12 months have passed. During this 12-month period, the newly acquired component would be considered accredited. (If you're wondering what kind of hospital would not accept Medicare and Medicaid reimbursements for services, most facilities in this category are government hospitals and small private-pay hospitals.)

If the hospital is like the majority of hospitals across the country and uses The Joint Commission for accreditation purposes, then the findings from the Extension Survey would be rolled together immediately with the results from the triennial survey, which may affect the status of the organization's accreditation.

Included with this Extension Survey is a one-day visit from an LSC specialist surveyor, who will conduct a building tour and review documentation for the new component. While this assessment is a bit more relaxed and informal, it still can have a major impact on the organization's accreditation. The process is also unannounced, which can come as a surprise for many facility managers.

"We underwent a Joint Commission Extension Survey about three years ago after opening a new patient tower," says John Scanlon, interim vice president of engineering and facilities at Loyola University Medical Center in Maywood, Ill. "It followed the same game plan as an actual survey, but it was just one LSC surveyor for a single day. Therefore, the surveyor did not perform an in-depth document review but spent most of the time touring the new facility, discussing interim life safety measures, and talking though our Environment of Care management plans and emergency management. All in all it was a good experience.

"Overall, it was similar to our regular survey, but in less detail. We had an LSC surveyor for about half a day who spent most of the morning looking at each of the Environment of Care management plans and other documentation," says Scanlon. "He conducted a building tour checking the operation of doors and looking for penetrations in rated walls. Since we are a smaller facility, the building tour did not take long, so he had more time to examine nontraditional issues that he may not have looked at during a normal triennial survey."

Even with Extension Surveys, the process can vary depending on which LSC surveyor performs the survey.

Editorially speaking ?

Fri, 01 Jun 2012 04:00:00 GMT

Editorially speaking …

Editor's note: Each month, Senior Editor Brad Keyes, CHSP, offers his thoughts, concerns, and comments on issues pertaining to healthcare life safety.

Power strips

All too often, facility managers and safety officers want standards or codes that clearly tell them what to do, especially when it comes to issues in which they may not have very much expertise. Take power strips as an example. I never was an electrician or an electrical engineer. When I worked at a hospital, I remember maintenance staff coming to me (I was the safety officer) and asking what the codes and standards said about power strips. They wanted clear direction regarding whether they were permitted and what types could be used. I remember being very frustrated because the NFPA codes and standards were rather silent on the subject, and they still are. I don't remember exactly what I told them at the time, but I'm pretty sure it wasn't a decision I would be proud of today. That is why I am very impressed with Mark Addis' approach to figuring out what power strips are permitted in which specific areas for San Francisco General Hospital. He used a scientific approach to analyze and evaluate his needs and carefully selected different grades of power strips based on UL listings and standards. He has shown us that where the codes and standards are not clear, a basic scientific approach to the solution is always a sure bet. Good going, Mark!

Electronically monitored fire extinguishers

If you think something is missing from the story of the electronically monitored fire extinguishers, you're right. I did not identify the various manufacturers of the electronic system, and for good reason. I did contact one of them and we discussed his product, but when I mentioned it did not meet the requirements for the current adopted edition of NFPA 10 (the 1998 edition), the mood of the conversation changed. He said he had The Joint Commission's approval (not endorsement, but approval) in writing, which he shared with me, but I noted that The Joint Commission is only one of maybe five or six authorities having jurisdiction (AHJ) that a hospital must deal with. In the end, the manufacturer asked me not to write the story as he thought it would be bad for his business. I said I felt I needed to be responsible to my readers and write the truth, so I compromised and wrote the story without identifying the manufacturers.

Path of egress in a construction zone

This story has its genesis in a telephone conversation I had with a client, who was struggling to ensure there were two paths of egress for staff from a physicians' sleeping area during a construction project. The construction did not include the physician sleeping suite, but it did impair the main path of egress to an exit from the suite. There was another path, but it exceeded the maximum allowable travel distance. As the story explains, a path of egress into a construction zone is never desirable, but there are circumstances where it may be necessary, provided alternative life safety measures are implemented.

Extension Surveys

I remember performing Extension Surveys when I was an LSC surveyor for The Joint Commission. They were focused on a specific area of the hospital, usually a new patient wing or a significant change to a program. I don't remember anything significant resulting from these surveys; they pretty much followed the agenda of a regular triennial survey. I do remember hospitals struggling with commissioning documentation, though. Basic fire safety features like sprinkler systems and fire alarm systems require a contractor's certification and commissioning documentation. This is required before the organization can occupy the facility and is usually reviewed by the local or state AHJs in order to receive an occupancy permit. It is surprising how frequently this documentation gets misplaced after the facility receives permission for occupancy.

Questions & Answers

Fri, 01 Jun 2012 04:00:00 GMT

Questions & Answers

Editor's note: Each month, Senior Editor Brad Keyes, CHSP, consultant for Keyes Life Safety Compliance, answers your questions about life safety compliance. Our editorial advisory board also reviews the Q&A column. Follow Keyes' blog on life safety at www.keyeslifesafety.com for up-to-date information.

Medical gas alarm panels

QIs it a requirement to keep access to the medical gas alarm panel clear in a similar manner that access to medical gas shutoff valves must remain clear? These alarm panels seem to always be mounted in a crowded area.

AThe medical gas shutoff valve clearance you are referring to is found in NFPA 99 (1999 edition), section 4-3.1.2.3 (d), which requires the zone valves to be readily operable from a standing position in the corridor on the same floor it serves. While it does not specify a clearance in inches or feet, this is frequently interpreted by many authorities having jurisdiction (AHJ) to be 36 inches clearance in front of the valves, which is similar to the 36-inch clearance required in front of electrical panels. Section 4-3.1.2.2 (b) 2 of NFPA 99 requires the master medical gas alarm panels to be placed in two locations: 1) in the principal working area of the individual responsible for the maintenance of the medical gas systems, and 2) in an area where the alarm panel is continuously monitored, such as a switchboard area. Section 4-3.1.2.2 (d) requires area alarm panels to be located at the nurses' station or some other location that will provide responsible surveillance. NFPA 99 does not specify any clearance requirements for these alarm panels, so as long as they can be monitored at the locations listed, then you are meeting the requirements of the standard.

Medical air dew point alarm

QI have a compressor that delivers medical air for our patients and want to know what the requirements are for the alarm system for the air dryers. Where do the alarms have to sound, and what is the range for the dew point for the dry air?

AThe requirements for medical air and related accessories are found in NFPA 99 (1999 edition), Chapter 4. Section 4-3.1.1.9 describes multiple requirements for monitoring the air that is discharged from the medical air compressor. The point where the air quality must be monitored is downstream of the regulators, but upstream of the piping systems. Dew point as well as carbon monoxide must be monitored continuously, and when these parameters are out of their normal range, they must actuate an alarm in the mechanical room where the medical air compressor is located and on the medical gas alarm master alarm panels (mentioned in the above question). The dew point monitor must activate an alarm when the dew point exceeds 39%.

Unannounced fire drills

QHow would you define unannounced when it comes to fire drills? There doesn't appear to be anything in the standard that explains what this means. What do you say?

AThe standard you are referring to is the Joint Commission Environment of Care standard, which limits unannounced drills to no more than 50% of all drills. This is not a life safety issue as the Life Safety Code® (LSC) does not address it. In lieu of asking The Joint Commission what it meant, I would define announced fire drills as having a published schedule of future drills that is shared with others. Another example of announced drills is having the switchboard operators announce overhead, "This is a drill," when the fire alarm is activated. The reason announced drills are undesirable is staff will react less than optimally when they know the fire alarm is only a drill.

Mechanical room storage

QIs it prohibited to store items in a mechanical equipment room? We have different opinions at our hospital as to what is allowed and what is not allowed. Do sprinklers make a difference? Your answer would help decide this issue.

AAs far as I can tell, there is nothing in the LSC preventing noncombustible items from being stored in a mechanical room that does not contain fuel-fired equipment. Also, I don't see any problem with storing combustible items in a non-fuel-fired equipment room, provided it meets the requirements of 18/19.3.2.1 for hazardous rooms. Now, I do see some NFPA documents (such as NFPA 13 and NFPA 72) that prevent storage of items in certain equipment rooms in special situations. But as far as general storage in mechanical rooms that do not have fuel-fired equipment, I don't see why not. What drives AHJs to cite this as a problem is the amount of storage that accumulates in those rooms. There are documented situations where storage on top of ductwork and air handlers has been in such massive quantities that it blocks access to mechanical equipment. In some instances, the amount of storage discourages the regular maintenance of equipment because storage has to be moved to gain access. The purpose of the mechanical room is to house mechanical equipment, and when storage interferes with this objective, that's when problems begin. Some organizations have portioned-off sections that prevent stored items from obstructing access to mechanical equipment. That confines and limits the amount of storage to a certain quantity and keeps access to mechanical equipment clear.

Contents and furnishings

QOur entire hospital is protected with automatic sprinklers. Do the contents and furnishings in our patient rooms need to meet a flame spread standard?

AThe answer to this question is yes in some situations, and no in others. Flame spread is a term used for measuring the combustibility of interior finishes on walls and ceilings. They are categorized into three classes: Class A for materials with a flame spread of 0-25, Class B for materials with a flame spread of 26-75, and Class C for materials with a flame spread of 76-200. The flame spread rating of any material is based on an arbitrary scale where cement board has a 0 rating and red oak has a 100 rating. Floor coverings are classified and measured based in a similar way, but they use radiant flux ratings since most floor coverings will be ignited by radiant heat. Furniture and mattresses do not have to meet flame spread requirements as defined for interior finishes. However, newly introduced furniture and mattresses must meet flame ignition tests as described in sections 10.3.2 through 10.3.4 of the 2000 edition of the LSC, unless the rooms or spaces in which they are located are protected with automatic sprinklers. Draperies and curtains have to meet the fire resistance requirements of section 10.3.1, and there are no exceptions for being sprinklered. However, there is an exception for shower curtains (see 19.7.5.1). Combustible decorations are not allowed in healthcare occupancies, unless they are flame-retardant or if they are in such limited quantities that a hazard of fire spread is not present. So for your hospital, which is fully protected with automatic sprinklers, you do not have to meet flame ignition tests for furniture and mattresses, but your curtains and draperies do have to meet certain flame resistant requirements found in section 10.3.1.

Fire drill requirements

Fri, 01 Jun 2012 04:00:00 GMT

Fire drill requirements

One of the Q&As in this month's issue dealt with fire drills. The question asked what constituted an unannounced drill, but we thought you may be interested in knowing what else is required for a fire drill.

Frequency

Fire drills in healthcare occupancies (e.g., hospitals, nursing homes, limited care facilities) and ambulatory care occupancies (e.g., surgical centers, dialysis centers, gastroenterology labs) are required to be performed once per quarter per shift. Authorities having jurisdiction like to see that you perform the fire drills at different times on each shift so staff do not become familiar with the time of day and the alarm. Fire drills for business occupancies are required once per shift per year.

Fire alarm transmission

Each fire drill must transmit an alarm signal all the way to the emergency services responding company (local fire department). This is often misunderstood to mean transmittal of the alarm signal just to the monitoring company. The interpretation of the code requires that the local fire department (or the 911 center) receives the signal during each fire drill, even if it comes from the monitoring company.

Simulation of emergency fire condition

Each and every fire drill must have some sort of emergency simulation, meaning you must "act" out a fire scenario. All too often some individuals merely walk up and ask a staff member a few questions about the fire response plan and walk away thinking it was good enough. Each drill must simulate emergency conditions, including the evacuation of a simulated patient to an adjoining smoke compartment. And as mentioned, the fire alarm must be activated as well, with the exception being the night shift (9 p.m. to 6 a.m.).

Evaluation

The fire drill evaluation or critique must analyze the staff's response; the fire alarm system's response; and the building's response, based on the organization's fire response plan. If your plan requires staff to activate the alarm and call the operator, then you must evaluate that they did so. If the plan calls for staff to close doors and be on the alert for orders, then the evaluation must address that response as well.

Healthcare Life Safety Compliance, June 2012

Fri, 01 Jun 2012 04:00:00 GMT

Electrical power strips: How they are regulated by the Life Safety Code

How does one go about selecting the appropriate power strips when the codes and standards do not specify the proper types? One hospital found a new way after undergoing a CMS validation survey.

"They immediately began writing citations wherever they found power extension cords or power strips," said Addis. "The power strips connected to computers did not have surge protection."

That said, power strips were not the only electrical issues that were cited during this CMS validation survey.

One other peculiarity of the UL 60601-1, according to Addis, is it actually looks for a ground to ensure its integrity. Therefore, this device will not work where isolated power systems are in use.

"The UL 1363 is the one I purchased for operating rooms and works very well with isolated power systems," said Addis. "It can also be used inside the 6-foot patient ring."

This has gone a long way toward creating a safe environment, and there is no longer any concern about using the incorrect power strip.

Managing electronically monitored fire extinguishers

One of the newer devices on the market is an electronic system to monitor each fire extinguisher for certain functions. The system will trigger an alert in the following circumstances:

An extinguisher is removed from its mounting bracket
The pressure inside an extinguisher's cylinder drops
Something is placed in front of an extinguisher, blocking access to it

Finally, the pressure of the cylinder is electronically monitored using a special pressure gauge that sends an electronic signal when the pressure drops below an acceptable level.

Extinguisher located in designated place
No obstructions to access
Pressure in the operable range
Fullness as determined by hefting the extinguisher
Condition of tires for wheeled extinguishers
Indicator for nonrechargeable extinguishers using a push-to-test pressure indicator

Verifying that operating instructions on nameplates are legible and face outward
Checking for broken or missing safety seals and tamper indicators
Examining for obvious physical damage, corrosion, leakage, or clogged nozzle

High frequency of fires in the past
Severe hazards
Locations that make them susceptible to mechanical injury or physical damage
Exposure to abnormal temperatures or corrosive atmospheres

Understanding path of egress in a construction zone

Corridor width is not the only issue that the project team needs to be concerned with:

The interior finish in the exit access corridor is required to be Class A or Class B, which means the flame spread rating of the walls and ceiling cannot exceed 75.
The headroom in the path of egress is required to be no less than 7 feet 6 inches, with projections from the ceiling not less than 6 feet 8 inches above the floor.
The walking surface cannot have an abrupt change in elevation of more than ¼ inch.
Nothing is allowed to obstruct access to the exit or the visibility thereof.
The corridor itself is required to be separated from all other areas of the facility with 30-minute fire-rated barriers that extend from the floor to the deck above, and openings may be equipped with non-rated smoke-resistant, positive-latching doors if the smoke compartment is not protected with sprinklers.
The corridor barriers may be non-rated and resist the passage of smoke and extend from the floor to the ceiling, provided the ceiling also resists the passage of smoke, and openings may be equipped with non-rated smoke-resistant, positive-latching doors if the smoke compartment is protected with automatic sprinklers.
The ceiling is required to resist the passage of smoke if equipped with fire alarm smoke or heat detectors; sprinkler heads; or if the corridor separation barriers are smoke resistant and do not extend any farther than from the floor to the ceiling.
Illumination of the path of egress is required to be maintained to be at least 1 foot-candle as measured at the floor.
Markings of the path of egress are required with appropriately located "Exit" signs.
Temporary construction barriers must be one-hour fire rated with appropriately rated doors if the construction area is not protected with automatic sprinklers. Note: Some AHJs permit fire-retardant plastic visqueen in lieu of fire-rated barriers.

To be sure, exiting into a construction zone to get to an exit is not desirable, but at times, it may be the only option that you have.

Extension Surveys: A little-known piece of accreditation compliance

Changes for facility managers with the adoption of the 2012 edition of the LSC

Tue, 01 May 2012 04:00:00 GMT

Changes for facility managers with the adoption of the 2012 edition of the LSC

CMS has stated that it will begin the process of adopting a more recent edition of NFPA 101, the Life Safety Code® (LSC), for healthcare organizations that receive reimbursement for Medicare and Medicaid services. While there may be a few hospitals in the country that do not accept government reimbursement for services, the vast majority of hospitals do-and they rely heavily on the government's payments, which represent a significant portion of their income.

CMS has not said when it will adopt the 2012 edition of the LSC, but experts in the industry believe it will be in 2013 or 2014, due to the amount of time required for public review and comments. When the hallowed day of adoption arrives, accreditation organizations such as The Joint Commission, the Healthcare Facilities Accreditation Program, and Det Norske Veritas will be permitted to follow suit. Until then, accredited hospitals must continue to use the 2000 edition of the LSC. While this is not a bad edition, it has shown its age in certain areas.

Suites of rooms represent one area that will have a major impact-and provide major relief-for hospitals. The 2000 edition of the LSC limits exiting from the suite to exit access doors. This was frequently misinterpreted by authorities having jurisdiction (AHJ), facility managers, and consultants as meaning only doors opening onto an exit access corridor were permitted, and exiting from the suite to an actual exit, such as a stairwell or a direct exit to the outdoors, was not acceptable.

The members of the NFPA 101 Technical Committee on Health Care Occupancies wanted to correct this confusion, and the 2012 edition of the LSC clearly states that where two or more exits are required from a suite, one of the exits must be to the corridor, but the other is permitted to be to an exit stair, an exit passageway, a horizontal exit, or a direct exit to the outdoors. This is a great solution to a confusing problem as many patient sleeping suites have been constructed with one of the required exits served by a stairwell.

In addition, the second exit from a sleeping suite is permitted to be through an adjoining suite, provided that the separation between the two suites complies with the corridor requirements. That means if the corridors are required to be smoke-resistant construction and extend from the floor to the ceiling with doors in openings that are required to latch, then the separation between the two suites must be the same. The annex section for this code reference explains that the 100-foot maximum travel distance only applies to the suite under consideration. That means once you cross over into the adjoining suite, the maximum travel distance resets. Granted, the annex section is not considered to be a mandatory section of the LSC, but AHJs often use the annex as a guide to help understand how to interpret the LSC.

The next significant change is the actual size of the sleeping room suite. The 2000 edition had a flat limitation of 5,000 square feet, and any suite that exceeded that size was considered noncompliant. This presented numerous challenges, as many suites did not have doors to patient sleeping rooms that were equipped with positive latching hardware. Because a suite designed and constructed to be over 5,000 square feet no longer qualified as a suite under the 2000 edition, the doors to the patient rooms technically opened onto a corridor and thus, by code, they were required to positively latch. This was not usually discovered until years later when The Joint Commission's LSC specialist surveyors began to cite hospitals for noncompliance. Hospitals had to take corrective action to resolve this problem, which often included installing latches on the patient room doors or requesting equivalencies for an oversized suite.

The technical committee decided to increase the suite size limitations for the 2012 edition, but these changes are based on certain features of fire safety. Sleeping suites may now be up to 7,500 square feet in size, provided the smoke compartment where the suite is located is protected throughout with automatic sprinklers and smoke detection. The smoke detection requirement is not required if the automatic sprinklers are quick-response sprinklers. The technical committee also decided to go one step further and allow sleeping suites to be up to 10,000 square feet in size, provided the suite meets all of the following requirements:

All of the patient sleeping rooms are required to be arranged to allow direct supervision from a normally attended location within the suite. Glass walls and cubicle curtains are permitted.
The entire suite is required to have total coverage with automatic smoke detectors.
The entire suite is required to be protected with automatic quick-response sprinklers.

These changes will be a welcome relief to many facility managers and project managers with older noncompliant patient sleeping suites.

For non-sleeping suites, the maximum size limitation remains 10,000 square feet, but these suites may take advantage of the changes involving exiting. One of the two required exits must be to a corridor, but the other required exit may be to an exit stairwell, an exit enclosure, a direct exit to the outdoors, or a horizontal exit. Also, one of the two required exits may be through an adjoining suite provided the separation between the suites is the same as required for a corridor. Now, keep in mind that for non-sleeping suites, the exit through an adjoining suite does not have the provision allowing the travel distance to reset, as sleeping suites do.

The only note in the annex section for non-sleeping suites says the adjoining suite is not considered an intervening room.

Speaking of intervening rooms, the 2000 edition limited the maximum travel distance to an exit access door in non-sleeping suites to 100 feet through one intervening room and 50 feet through two intervening rooms. The 2012 edition has changed the limit to simply a maximum of 100 feet-period. But the maximum travel distance to an exit from anywhere in a non-sleeping suite is still 150 feet for non-sprinklered buildings and 200 feet for buildings protected with automatic sprinklers.

Corridors

Wall-mounted projections on corridors are still limited to a maximum of 6 inches, but the Tentative Interim Amendment 787 issued in April 2004, which applies to the 2000 edition of the LSC, said 4 feet of space was required between the wall-mounted projections. Originally, the amendment was intended to be limited to alcohol-based hand rub dispensers. The 2012 edition of the LSC no longer restricts what can be mounted to the wall as long as it meets the 6-inch projection requirement, and projections are now allowed to be spaced in a "non-continuous" fashion-in other words, you just have to have a space between the objects. So, the 2012 edition clearly permits wall-mounted charting desks, telephones, bulletin boards, sharps containers, and anything else as long as they meet the restrictions.

The new LSC will now permit certain wheeled equipment to be left in the corridor, provided the clear width of the corridor is not reduced to less than 5 feet, and provided there is a written fire safety plan and training program that addresses the relocation of the wheeled equipment during a fire. Permissible wheeled equipment is limited to the following:

Equipment and carts in use
Medical equipment not in use
Patient lift and transport equipment

The annex section of the LSC cautions the reader that for medical equipment, the terms "not in use" and "in storage" are not interchangeable, but it does not offer any explanations to differentiate between them. It may be easy for a surveyor to determine that medical equipment with plastic covers lined up in a corridor is "in storage," but without a tangible sign, it may be difficult for him or her to make the same decision when it comes to IV pumps or blood pressure cuff monitors.

And what about the relocation of wheeled equipment during a fire alarm? Where will the staff wheel the equipment to get it out of the corridor? Empty patient rooms, perhaps, but you cannot count on a patient room being empty. Organizations will need a designated place to relocate all of the medical equipment left unattended in the corridor. It may prove to be very challenging for safety officers and facility managers to train the nursing staff on only leaving approved equipment in the corridor. Staff may not understand that certain pieces of equipment, like beds and soiled linen hoppers, are not on the list of approved items.

Finally, fixed furniture will now be allowed on one side of corridors that are at least 8 feet wide, provided the furniture does not extend more than 2 feet into the corridor and is securely fastened to the wall or floor. The smoke compartment where the fixed furniture is located must be fully protected with automatic sprinklers and smoke detectors, or the furniture must be arranged to allow direct supervision by the staff. Groups of fixed furniture cannot exceed 50 square feet and must be at least 10 feet apart from each other.

A case for contracted fire alarm testing

Tue, 01 May 2012 04:00:00 GMT

A case for contracted fire alarm testing

An article in the April issue of HLSC discussed how one hospital was seriously reviewing the process by which its fire alarm system was tested and maintained. The hospital found many frustrations with its current testing contractor, to the point where it considered hiring its own in-house fire alarm technicians. By taking this step, the hospital felt it could have better quality control for its testing and inspection process. In contrast to the April story, this article examines why a hospital may want to leave the important service of fire alarm testing to a qualified contractor.

"In regards to the scheduled testing of fire alarm systems, healthcare facilities have a vested interest in maintaining safety compliance as well as limiting their liability exposure," says Gene Rowe, business development manager at Affiliated Customer Service in Downers Grove, Ill. "This might seem like a good reason to conduct in-house testing, but not necessarily the right decision. Reputable third-party testing companies are partners that understand their responsibilities and ensure they are met, for their own success as a company as well as for the safety of those that rely on their integrity."

Rowe believes in-house technicians who are overly familiar with the facility and the system (due to interacting with them on a daily basis) will develop expectations of what is going to happen when testing. They will know whether renovations have been done in one area, or whether another area has remained unchanged for 20 years. If they know the conditions in an area are the same as three months ago, they will expect the outcome of their tests to also be the same. Testing becomes a paper drill, and deficiencies become overlooked.

"This is not to suggest that they all look to 'pencil whip' their inspections," says Rowe. "However, they are not immune to human nature. Additionally, correcting deficiencies identified during system testing must compete with the everyday requirements of their position. An in-house technician may not view the needed corrections as a high priority when other maintenance issues emerge on a daily basis." And once deficiencies are given a lower priority, it may become routine to postpone life safety repairs until an inspection looms.

A third-party testing agency doesn't have the same pressures or overfamiliarity. The third party may know the building well, and it may even have conducted tests there for years, but it won't know whether small changes have been made between its inspections. As a result, the third party will conduct its tests with fresh eyes and fewer expectations.

Rowe goes on to explain that the installation of-or interaction with-fire alarm equipment does not translate into understanding what constitutes proper operation of the system and its associated outputs. As an example, smoke detector testing as performed by in-house personnel will probably aim to simply activate the device. The tester will spray as much canned smoke as needed until the device alarms. He or she may not have the equipment or the knowledge to determine whether a detector is operating within its UL-listed sensitivity range-a subject that comes up when a room is filled with smoke but the alarm does not sound. The in-house tester's reports will show that the device was "tested," but in reality, all that's been verified is the accuracy of the detector's displayed description and whether it will eventually go off given enough smoke.

"They confuse a programmed sensitivity level [which is actually the alarm threshold] that can be viewed from the panel menu with its ability to activate within that threshold," suggests Rowe. "This ability is what the sensitivity report required by NFPA 72 is referring to. This area of concern is especially applied to code-compliant duct detector testing, which involves the measure of airflow from start to end of the detector sampling tube system, as well as secondary power testing, which measures specific gravity readings from batteries. This type of code-compliant testing is rarely performed by in-house personnel, but will seriously jeopardize the expected operation of the system if inadequate when relied upon."

Rowe is also concerned about adequate verification of outputs. Would in-house personnel check to see whether smoke dampers operate when required, that the dampers fully seal when they close, and that rolling overhead fire doors properly drop when the initiating device is activated?

And how about elevator recall? Will all fire alarm interface devices be tested to ensure the elevator recalls to the appropriate floor? Will infant security systems that interface with the fire alarm system be tested properly? The fire alarm interface between delayed-egress and access-control locks on egress doors needs to be properly tested. The smoke evacuation system controlled via the building automation system needs to be activated during the fire alarm test. Would in-house testers even know to look for these interfaced devices? Full knowledge of how fire alarm systems are integrated with the various building systems, as well as the details of when such integration is required, is something that a reputable fire alarm service agent would have.

Documentation is always a top concern of medical facilities-with good reason. An experienced, knowledgeable fire alarm service agent knows the requirements of the appropriate authority having jurisdiction (AHJ) and will review the reports with the client to ensure the reports meet requirements and, most importantly, are meaningful. Documentation is of no use if it cannot be referenced and understood by the chief engineer and the reviewing authority. Rowe believes a testing form straight out of NFPA 72 will most likely be inadequate for medical facilities. The testing form is a base and generic form that is used for less complicated systems. A handwritten form, or a form missing vital information, isn't going to inspire confidence from the reviewing authority, and the result will be a more comprehensive evaluation from the AHJ surveyor, whose job is to ensure compliance. The bottom line is that appropriate documentation can be easily achieved if the medical facility partners with a reputable firm that foresees the facility's needs and engages in proactive communication.

Surveyors are placing more emphasis on fire alarm test reports than ever before because they have more time during the survey to do so. Not only will surveyors want to know whether the devices were tested at the proper intervals, but they will also want to make sure the organization has resolved any deficiencies discovered during the testing process. Devices that are identified as noncompliant during the test need to be addressed the same day the deficiency is discovered, or assessed for alternative (or interim) life safety measures. If an initiating device or an occupant notification device is found to be defective, this vital information cannot be withheld until the entire system is tested. Instead, a competent third-party fire alarm contractor will meet with the facility's representative on a daily basis to discuss the results of each day's test.

The cost savings of in-house testing versus third-party testing may depend on the facility. A facility large enough to consider in-house testing must weigh the value gained from a third party's knowledge and experience and the liability aspects the facility will face if it elects to test with its own staff. Again, Rowe believes it comes down to selecting the right company to perform the work. Reputable companies are partners that understand their responsibilities and ensure they are met, for their own success as a company as well as for the safety of those who rely on their integrity. It's important to note, too, that "reputable" does not necessarily mean "big."

"Reputable means responsible, capable, and qualified-attributes that can be ascertained during contract negotiations," says Rowe. "A reputable company is interested in maintaining safety compliance for their customer as well as limiting their customer's and their liability exposure. It's a partnership that can become a lasting relationship between facility manager and contractor."

Director of engineering for The Joint Commission explains stance on equipment maintenance

Tue, 01 May 2012 04:00:00 GMT

Director of engineering for The Joint Commission explains stance on equipment maintenance

During a March webinar presented by Joint Commission Resources, George Mills, MBA, FASHE, CEM, CHFM, CHSP, the accreditor's director of engineering, expressed his frustrations with CMS' apparent reversal on an agreement it had made with The Joint Commission concerning equipment maintenance.

"There's a couple of things CMS is doing right now that we're looking at and challenging," said Mills. "CMS has given Joint Commission deemed status, so that's why when we accredit your organization, you have access to federal money through the Medicare and Medicaid Act [of 1964], which CMS oversees the dispersion of funds."

Mills explained that CMS has said, through its Conditions of Participation, that hospitals must follow manufacturer recommendations only for preventive maintenance (PM) activities on medical and utility equipment. For over 20 years, The Joint Commission has taken a more scientific approach to equipment maintenance, and its standards allow the hospital three choices of how to set its frequencies and methods, which include risk level, hospital experience, or manufacturer recommendations.

"In 2010 we approached CMS and were given permission to continue to use our process," said Mills. "They agreed with us to allow us to use risk level, hospital experience, and manufacturers' recommendations in determining equipment maintenance."

In December 2010, Det Norske Veritas asked for the same provision, and CMS granted it because it had done so for The Joint Commission, said Mills.

"Then in December 2011, CMS issued an interpretive document called a 'S&C Letter' where they modified their position and said all life support equipment has to be tested according to the manufacturer's recommendation only," he said. "They also said all equipment, regardless whether it is life support or non-life support, had to follow manufacturers' recommendations for the method of testing on the equipment, which again was contrary to the agreement that we had," he continued.

"When they said that, I went to our leadership and said, 'This is not meeting the spirit of what we accepted from CMS before and is contrary to the way we are doing things, and there is no science behind this decision.' I asked my leadership if we could challenge CMS on this and they said yes. I have a meeting scheduled with CMS to discuss this," said Mills. "We have no incidences of equipment failing due to a lack of PM and resulting in patient injury. Equipment issues related to patient injuries are all tracked back to user errors, not due to PM cycle."

With the assistance of other experts in the field, The Joint Commission has determined that if hospitals were required to follow medical equipment manufacturers' recommendations in regards to PM, there would be an increase in biomedical staff alone of up to 25%. The accreditor also estimates that an additional $1-$2.5 billion would be needed across the country to obtain the additional resources necessary to meet the CMS requirement. Further, Mills believes there is no evidence that the current Joint Commission method of equipment PM is causing any harm to patients. If such evidence existed, he would be the first to request a change.

"We have not been told that the S&C Letter applies to us. So I'm telling people who call from our accredited organizations who ask what to do to keep doing what they have been doing in the past, and if you have a CMS survey, you will have to respond to them. Try to buy yourself some time because we will go to the mat with them on this issue," said Mills.

Other issues

Turning to other topics, Mills said that environment of care or life safety deficiencies accounted for six of the top 10 most-cited findings for all hospital surveys in 2011. As in past years, the following issues once again made the top 10 list:

LS.02.01.10, penetrations in rated walls
LS.02.01.20, corridor clutter
LS.02.01.30, hazardous areas
EC.02.03.05, fire safety testing
EC.02.06.01, patient safety
EC.02.03.01, fire safety

Here's what Mills had to say on the above-listed topics and more:

Rated wall penetrations. Mills expressed frustration with this issue and offered advice on how hospitals can monitor this topic more effectively.

"57% of the surveys had findings of penetrations in rated walls. This frustrates me. To have holes in these walls and not manage them isn't the fault of IT or a contractor. I really believe it is the fault of facility management," he said. "We're supposed to be facility managers, and we should be able to manage these things. Barrier management really isn't as hard as people are making it. I suggest you put a bounty on those individuals who have access to the barriers."

Get your nursing staff, housekeepers, and technicians involved-ask them to call security if they see someone on a ladder above a ceiling and there's no permit affixed to the ladder, Mills said.

"An officer can come and confront the individual who is without a permit and tell them permits are only available in engineering at 8 a.m. Have the contractor escorted from the building, and you can bet the contractor will be back the next day at the appropriate time to obtain a permit," said Mills. "A reward like a pizza party can be used for the hospital staff who initially reports the non-permitted contractor."

Corridor clutter. This is the second most frequently cited item, and Mills noted that the Statement of Conditions' Plan for Improvement section cannot be used to resolve corridor clutter. Attended items, such as carts for housekeeping, linen, and food service, are allowed as long as there is someone directly involved and responsible for those carts. But after 30 minutes of being unattended, all items not in use, other than crash carts and isolation supply carts, must be removed from the corridor.
Defibrillator maintenance. Mills informed listeners that defibrillators are now considered to be life support equipment and thus require identified maintenance activities. A maintenance strategy for defibrillators could include a range of activities, from a visual inspection of a single-use automatic external defibrillator to scheduled PM maintenance, he explained.
Risk assessments. These are simple and easy to perform, according to Mills. You should use them to evaluate any issue for which you are unable to come to a clear decision. Mills advises listing the advantages (or the safe view) of the issue on one side of the paper and the disadvantages (or the unsafe view) on the other. Whichever side outweighs the other is your answer. Examining risk in the environment is another way of looking at hazardous areas. The hospital is required to identify risks to safety and security in the environment that could affect patients, staff, and visitors.

"The best way to evaluate your environment is through environmental rounds," said Mills. "That's a great opportunity to look for things that are related to any kind of risk assessment issue. Once you identify a risk, we expect you to do something about it."

Interior spaces. These spaces must meet the needs of the patients and be safe and suitable for the care and treatment provided. Unsafe patient care areas will receive findings, according to Mills. This includes spaces containing unsafe equipment as well as a building's exterior grounds.
Eyewash stations. The hospital is required to minimize risks associated with the handling, storage, transportation, and use of hazardous chemicals. Mills explained that eyewash stations are a large part of managing this risk.

"Eyewash stations are only required in areas where you have caustics or corrosives," he said. "Blood and body fluids are neither of these. I would expect to see eyewash stations in the power plant because of the caustic materials used in the water treatment for boilers."

Other areas that should have eyewash stations are laboratories and storage areas for floor scrubber machines, where batteries are charged. "I would expect to see eyewash stations in those locations. I would not expect to see them on a nursing unit, but if they are installed there, then you need to maintain them according to the ANSI Z358 standard for proper testing, which we believe to be five to 10 seconds every week and 10-15 seconds every month, and annually for a substantial run to get good clear water," said Mills. "Water temperature of eyewash stations is required to be tepid, which is between 60-90 degrees Fahrenheit. If you cannot meet the minimum temperature, then perform a risk assessment to evaluate if the cooler water temperature is not a health hazard."

Alcohol-based hand rub (ABHR) dispensers. The Joint Commission is now permitting ABHR dispensers to be mounted no less than 1 inch from the edge of an electrical source, such as a switch or outlet, said Mills. In addition, the ABHR dispenser cannot be mounted above an electrical source and has to be offset horizontally at least 1 inch to the side.
Endoscopes. These are a large concern for The Joint Commission, according to Mills. Many adverse patient outcomes have been attributed to poorly cleaned and stored endoscopes. Mills said scopes should be properly hung in a cabinet after cleaning, and the ends of the scopes should not be resting on a cloth. Scopes may be stored in the same room as processing, but there must be at least 3 feet of separation from the wash area. According to Mills, the contamination source for scopes is water droplets (e.g., from splashing), not airflow.
Alarms and fire safety. Alarms are back on The Joint Commission's short list. Alarm fatigue and silencing of devices are issues that surveyors will zero in on. Additionally, Mills noted that beginning this year, Life Safety Code® surveyors will be required to gown up and go into the surgery department on every survey to interview clinical staff on specific issues pertaining to surgical site fires. Staff will be quizzed on their fire safety knowledge, including how often they receive such training and how often fire drills are performed.
Relative humidity. Effective January 1, 2011, The Joint Commission adopted the Facilities Guidelines Institute's Guidelines for Design and Construction of Health Care Facilities, 2010 edition. In that document is ASHRAE Standard 170, which permits relative humidity in a surgical setting to be 20% at minimum and 60% at maximum. CMS only allows a 35%-60% range, but according to Mills, CMS will permit the 20% minimum since the agency is evaluating current editions of codes and standards for potential adoption. The 35% minimum was originally set forth to prevent accidental sparks from static discharge, which could ignite flammable anesthetics. Since flammable anesthetics have been banned from surgeries since 1978, it is time to allow lower humidity ranges, which will save hospitals money on their energy costs. According to Mills, if CMS performs a validation survey, it will expect to see a minimum of 35% humidity and will cite hospitals that do not meet this value. If that occurs, Mills advises hospitals to write back to CMS in their Plan of Correction, claiming a hardship in obtaining 35% with their current systems and requesting a waiver.
Nonflammable medical gas storage. This is still a problem frequently cited by surveyors, according to Mills. Up to 12 properly secured E-size oxygen cylinders (less than 300 cubic feet aggregate total) are permitted to be stored in a single smoke compartment and open to the corridor (but not in the corridor) without special storage requirements. Once the aggregate total of medical gas exceeds 300 cubic feet per smoke compartment, all the cylinders are required to be stored inside a specially designated room of limited construction, with a door that can be secured against unauthorized entry. Oxidizing gases must be separated from combustibles by 20 feet, or 5 feet if the room is protected with automatic sprinklers. The oxidizing cylinders may also be separated from combustibles by an enclosed cabinet having a minimum fire rating of 1/2 hour.

Editorially speaking

Tue, 01 May 2012 04:00:00 GMT

Editorially speaking

Editor's note: Each month, Senior Editor Brad Keyes, CHSP, offers his thoughts, concerns, and comments on issues pertaining to healthcare life safety.

Changes with corridors

The lead article in this month's issue discusses some changes that facility managers will have to deal with when CMS finally adopts the 2012 edition of the Life Safety Code®. The changes involving suites of rooms are easy to accept, as they will be helpful for facility managers-but the changes involving corridors may present a challenge. The code will now permit unattended medical equipment to be left in the corridor, even if it is not in use. The code says it can't be stored in the corridor, but it can be left there even if it isn't in use. How will anyone, including a surveyor, know the difference?

And while transport equipment such as wheelchairs and gurneys will be permitted in a corridor, beds and soiled linen hoppers will not. Having worked in a hospital for many years, I can see that this distinction will be lost on most point-of-care staff. I suspect staff will feel free to leave a bed in the corridor if they see a gurney or a wheelchair in repose there.

What's more, the code requires all of this equipment to be removed from the corridor during a fire alarm-so where will it be relocated to? You'd best not count on a vacant patient room as in many cases there won't be one. That means there needs to be a designated place for storage outside of the corridor. So in summation, whoever is responsible for training will have their hands full trying to get staff to comply.

The Joint Commission vs. CMS

George Mills, the director of engineering for The Joint Commission, is certainly working overtime to advocate for accredited organizations. Currently, CMS only allows organizations to perform preventive maintenance (PM) on equipment based on what the manufacturer recommends, and not on any other basis. Going back as far as 2010, Mills negotiated a deal with CMS that would permit Joint Commission-accredited organizations to perform PM activities on medical and utility equipment based on a scientific method consisting of three elements:

The safety risk level of the equipment
Equipment history
Manufacturers' recommendations

According to Mills, CMS agreed in principle and told The Joint Commission to continue using this approach for equipment PM management. But then a policy change came from CMS (in the form of the "S&C Letter 12-07"), which was not what Mills and the agency agreed to. Apparently, CMS decided not to allow The Joint Commission's approach for equipment that is critical to patient safety and health.

Mills intends to continue to negotiate with CMS to change the agency's policy on this important issue. If you agree with his view, email him at gmills@jointcommission.org with your support and encouragement.

Contracted fire alarm testing

The article on contracted fire alarm testing is a continuation from last month's issue, which discussed the advantages of a hospital hiring its own fire alarm technicians. In considering this question, the whole issue of quality in the fire alarm testing process, including the reports, is at stake. I've seen some great contractors who do an excellent job for hospitals, and I've seen some lousy contractors who don't do such a good job, which can affect the hospital's accreditation status. The decision to hire your own fire alarm technician(s) should be based on the need to control the quality of the testing process, not economics. If you do not have any problems with the contractor that is currently testing your fire alarm system, then there should be no reason to make a change.

Questions & Answers

Tue, 01 May 2012 04:00:00 GMT

Questions & Answers

Editor's note: Each month, Senior Editor Brad Keyes, CHSP, consultant for Keyes Life Safety Compliance, answers your questions about life safety compliance. Our editorial advisory board also reviews the Q&A column. Follow Keyes' blog on life safety at www.keyeslifesafety.com for up-to-date information.

Sprinkler head clearance

QWe are about to install a new shelving system in a room that is protected with automatic sprinklers. I know we are supposed to maintain 18 inches clearance underneath the sprinkler heads, but I have been told there is an exception to that requirement. Is that true?

AYes, there is an exception to shelving height in regard to sprinkler heads, and it is found in NFPA 13 (1999 edition), section A-5-6.6. It states that the 18-inch clearance rule is not intended to limit the height of shelving on or against a wall where such shelving is not directly below a sprinkler head. The shelves along the wall and anything stored on them can extend above the imaginary plane located 18 inches below the sprinkler heads, as long as there are no sprinkler heads directly above the shelving. Other shelving (and items stored on the shelves) in the room that are not against the wall cannot extend above the imaginary plane that is located 18 inches below the sprinkler deflector. Now, this information is found in the annex section of the standard, which means it is not part of the enforceable standard. Instead, it is provided as a guideline to assist authorities having jurisdiction (AHJ) in understanding the intent of the standard. While most AHJs that inspect hospitals recognize and accept this explanatory information concerning shelving and sprinkler heads, not all do. I am aware of a few state AHJs that choose not to recognize this language and will not allow storage along the wall that exceeds the 18-inch rule. My suggestion is to contact your local and state AHJs to determine what they allow before you purchase and install shelving that may not be in compliance.

Alcohol-based hand rub dispenser spacing

QWhat is the actual spacing requirement for alcohol-based hand rub (ABHR) dispensers from electrical sources such as light switches in the hospital? I have heard it must be 4 feet from the switch, then I heard it is 6 inches from the switch, then someone said it is 1 inch. What is the actual requirement now?

AThis really depends on which AHJ is evaluating the ABHR dispensers. The NFPA allowed ABHR dispensers for hospitals in Tentative Interim Amendment (TIA) #787, issued in April 2004, and made it retroactive to the 2003 and 2000 editions of the Life Safety Code® (LSC). This TIA allowed ABHR dispensers to be mounted in corridors in hospitals, and it listed multiple requirements that hospitals must follow. One of the requirements involved the distance between the dispenser and potential ignition sources, such as light switches. This is what the TIA stated: "The dispensers shall not be installed over or directly adjacent to an ignition source." There was no statement of a minimum acceptable distance from dispenser to ignition source, only that they could not be adjacent to each other, so many accrediting agencies came up with their own interpretation. One of the better-known interpretations was from The Joint Commission; it required 6 inches from the centerline of the ABHR dispenser to the centerline (or edge, depending on which surveyor you got) of the ignition source. Since then, NFPA has stated in subsequent editions of the LSC that ABHR dispensers must be separated from ignition sources by 1 inch, side to side. But this 1-inch rule does not apply to the 2000 edition of the LSC. However, George Mills, director of engineering at The Joint Commission, recently stated that his agency will accept the 1-inch side-to-side definition, rather than the older 6-inch centerline-to-centerline interpretation. So, if you are Joint Commission-accredited, you are safe if you follow the 1-inch rule. However, for all other AHJs, the rule is whatever they say it is. I suggest you contact your state and local AHJs to find out how they interpret the word "adjacent."

Adding windows to fire-rated doors

QI have a supply room on a medical-surgical floor, and the door opens into the corridor. The corridor and the room are protected with automatic sprinklers. Because it is a supply room, we are using a 3/4-hour door. We would like to allow light to enter the room from the corridor and wanted to install a window in the door. Are we allowed to do this, and are we limited in the size of the window?

ASince you said the door is 3/4-hour fire rated, then section 8.2.3.2.1 of the LSC requires compliance with NFPA 80, Standard for Fire Doors and Fire Windows (1999 edition). NFPA 80, section 1-3.4 requires any modifications on fire-rated doors to be performed in facilities that are licensed by the door manufacturer. The manufacturer is responsible for ensuring the integrity and fire rating of the door, and any modifications to the manufacturer's specifications would jeopardize that rating. Therefore, the standard does not allow any field modifications to a fire-rated door, other than those required to install already-approved fire-rated hardware such as door closures, latch sets, and hinges. So yes, a window can be installed in a fire-rated door, but the door would have to be removed and sent back to an approved licensed facility where the modification could be made. As you can imagine, this is not a simple or inexpensive proposition, and it is not done very often. If the supply room is not required to have 1-hour fire-rated walls, then it may be more cost-effective to replace your door with a non-rated, smoke-resistant door that has a window already installed.

Communication cable wrapped to conduit

QI had a state inspector tell me that communication wires and cable in our hospital are not permitted to be tied to a conduit containing electrical wires. Is this true? If so, I will have to untie miles of communication wires from my conduit and rehang them.

AYes, I'm afraid this is true. Section 19.5.1 (section 18.5.1.1 for new healthcare occupancies) of the LSC requires compliance with section 9.1, which in turn requires compliance with NFPA 70, National Electrical Code, 1999 edition. Article 300.11 (B) of NFPA 70 does not permit anything to be attached to conduits, with one exception: Class 2 control cable may be attached to the conduit if it serves the circuit in the conduit. Apparently, the NFPA's concern is that heat from the electrical conductors inside the conduit may not dissipate adequately if there are additional cables and wires tied to the outside of the conduit. While it is highly unlikely that a single low-voltage cable wire tied to a conduit would cause a problem, I guess it is logical that many wires and cables could be a problem. The question is, where do you draw the line? NFPA appears to draw the line at one (1). So, I'm sorry to say, you will have to remove all the wires and cables from conduits in order to be compliant with the LSC. And by the way, do not attach those wires to your sprinkler pipes, either. That will cause a whole bunch of problems that you don't need.

CMS allows waivers for limited 2012 Life SafetyCode issues

Tue, 01 May 2012 04:00:00 GMT

CMS allows waivers for limited 2012 Life Safety Code issues

CMS issued a memo titled "S&C-12-21-LSC" in March, which will permit all healthcare organizations to submit a waiver request for certain new features of the 2012 edition of the Life Safety Code® (LSC). Specifically, the memo will allow organizations to adopt the following 2012 LSC sections:

18/19.2.3, Capacity of Means of Egress
18/19.3.2.5, Cooking Facilities
18/19.5.2, Heating, Ventilating and Air-Conditioning
18/19.7.5, Furnishings, Mattresses, and Decorations

The second and third items in that list will apply more to a long-term care program, such as a nursing home, rehab hospital, or facility-based hospice program, since an acute care hospital would not be too interested in having limited cooking facilities open to the corridor or gas-fired fireplaces in patient care common areas.

But the other two sections will be useful for the common acute care program. Now healthcare organizations will be allowed to submit a waiver request to CMS, through their state survey agency or accreditation organization, and they will not be required to prove unreasonable hardship as they would with a normal waiver request.

Regarding means of egress, corridors will be allowed to have certain wheeled equipment provided the width of the corridor is not reduced to less than 5 feet. The wheeled equipment that will be permitted includes:

Equipment and carts in use
Medical equipment not in use
Patient lift and transport equipment

Equipment is not permitted to be stored in the corridor, and "not in use" is not the same as "in storage."

Regarding decorations, combustible decorations will now be permitted to cover up to 20% of the corridor or room walls, ceiling, or non-fire-rated doors if the space is not protected with automatic sprinklers. If the space is protected with automatic sprinklers, then the allowed covered area is bumped up to 30%. If the space is a patient sleeping room in a smoke compartment fully protected with automatic sprinklers, up to 50% of the walls, ceiling, or door can be covered.

Check the referenced LSC sections carefully to ensure that you comply with all the requirements before requesting the waiver.

Healthcare Life Safety Compliance, May 2012

Tue, 01 May 2012 04:00:00 GMT

Changes for facility managers with the adoption of the 2012 edition of the LSC

All of the patient sleeping rooms are required to be arranged to allow direct supervision from a normally attended location within the suite. Glass walls and cubicle curtains are permitted.
The entire suite is required to have total coverage with automatic smoke detectors.
The entire suite is required to be protected with automatic quick-response sprinklers.

These changes will be a welcome relief to many facility managers and project managers with older noncompliant patient sleeping suites.

The only note in the annex section for non-sleeping suites says the adjoining suite is not considered an intervening room.

Corridors

Equipment and carts in use
Medical equipment not in use
Patient lift and transport equipment

A case for contracted fire alarm testing

Director of engineering for The Joint Commission explains stance on equipment maintenance

In December 2010, Det Norske Veritas asked for the same provision, and CMS granted it because it had done so for The Joint Commission, said Mills.

Other issues

LS.02.01.10, penetrations in rated walls
LS.02.01.20, corridor clutter
LS.02.01.30, hazardous areas
EC.02.03.05, fire safety testing
EC.02.06.01, patient safety
EC.02.03.01, fire safety

Here's what Mills had to say on the above-listed topics and more:

Rated wall penetrations. Mills expressed frustration with this issue and offered advice on how hospitals can monitor this topic more effectively.

Get your nursing staff, housekeepers, and technicians involved-ask them to call security if they see someone on a ladder above a ceiling and there's no permit affixed to the ladder, Mills said.

Corridor clutter. This is the second most frequently cited item, and Mills noted that the Statement of Conditions' Plan for Improvement section cannot be used to resolve corridor clutter. Attended items, such as carts for housekeeping, linen, and food service, are allowed as long as there is someone directly involved and responsible for those carts. But after 30 minutes of being unattended, all items not in use, other than crash carts and isolation supply carts, must be removed from the corridor.
Defibrillator maintenance. Mills informed listeners that defibrillators are now considered to be life support equipment and thus require identified maintenance activities. A maintenance strategy for defibrillators could include a range of activities, from a visual inspection of a single-use automatic external defibrillator to scheduled PM maintenance, he explained.
Risk assessments. These are simple and easy to perform, according to Mills. You should use them to evaluate any issue for which you are unable to come to a clear decision. Mills advises listing the advantages (or the safe view) of the issue on one side of the paper and the disadvantages (or the unsafe view) on the other. Whichever side outweighs the other is your answer. Examining risk in the environment is another way of looking at hazardous areas. The hospital is required to identify risks to safety and security in the environment that could affect patients, staff, and visitors.

Interior spaces. These spaces must meet the needs of the patients and be safe and suitable for the care and treatment provided. Unsafe patient care areas will receive findings, according to Mills. This includes spaces containing unsafe equipment as well as a building's exterior grounds.
Eyewash stations. The hospital is required to minimize risks associated with the handling, storage, transportation, and use of hazardous chemicals. Mills explained that eyewash stations are a large part of managing this risk.

Alcohol-based hand rub (ABHR) dispensers. The Joint Commission is now permitting ABHR dispensers to be mounted no less than 1 inch from the edge of an electrical source, such as a switch or outlet, said Mills. In addition, the ABHR dispenser cannot be mounted above an electrical source and has to be offset horizontally at least 1 inch to the side.
Endoscopes. These are a large concern for The Joint Commission, according to Mills. Many adverse patient outcomes have been attributed to poorly cleaned and stored endoscopes. Mills said scopes should be properly hung in a cabinet after cleaning, and the ends of the scopes should not be resting on a cloth. Scopes may be stored in the same room as processing, but there must be at least 3 feet of separation from the wash area. According to Mills, the contamination source for scopes is water droplets (e.g., from splashing), not airflow.
Alarms and fire safety. Alarms are back on The Joint Commission's short list. Alarm fatigue and silencing of devices are issues that surveyors will zero in on. Additionally, Mills noted that beginning this year, Life Safety Code® surveyors will be required to gown up and go into the surgery department on every survey to interview clinical staff on specific issues pertaining to surgical site fires. Staff will be quizzed on their fire safety knowledge, including how often they receive such training and how often fire drills are performed.
Relative humidity. Effective January 1, 2011, The Joint Commission adopted the Facilities Guidelines Institute's Guidelines for Design and Construction of Health Care Facilities, 2010 edition. In that document is ASHRAE Standard 170, which permits relative humidity in a surgical setting to be 20% at minimum and 60% at maximum. CMS only allows a 35%-60% range, but according to Mills, CMS will permit the 20% minimum since the agency is evaluating current editions of codes and standards for potential adoption. The 35% minimum was originally set forth to prevent accidental sparks from static discharge, which could ignite flammable anesthetics. Since flammable anesthetics have been banned from surgeries since 1978, it is time to allow lower humidity ranges, which will save hospitals money on their energy costs. According to Mills, if CMS performs a validation survey, it will expect to see a minimum of 35% humidity and will cite hospitals that do not meet this value. If that occurs, Mills advises hospi

Modifying the ICC buildingcodes

Sun, 01 Apr 2012 04:00:00 GMT

Modifying the ICC building codes

During last year's American Society for Healthcare Engineering (ASHE) annual conference in Seattle, it was announced that ASHE was advocating for a "One Code” concept for healthcare organizations. Recently ASHE announced that its advocacy staff has partnered with the International Code Council (ICC) to create the ICC Ad Hoc Committee on Healthcare, whose mission is to create codes that provide high levels of safety without unnecessarily wasting hospital resources.

We recently caught up with ASHE's director of codes and standards, Chad Beebe, AIA, SASHE, CHFM, CFPS, CBO, and asked him to clarify a few issues concerning this advocacy campaign.

"We began calling this the ‘One Code' project, but we're not trying to put NFPA or the Life Safety Code® [LSC] out of business, or remove [these] as a regulatory code for hospitals,” says Beebe.

The concept of "One Code” is not to eliminate any regulatory standard, but rather to align the existing standards so they no longer conflict but instead apply the same exceptions.

Beebe says the ICC is the organization that develops the International Building Code as well as the International Fire Code. These codes are used in approximately 98% of all jurisdictions across the country in construction projects, including hospitals.

"What we are trying to do is get the codes to align so that it's one concept or one philosophy being used for both the NFPA 101 Life Safety Code and the ICC Building Code,” says Beebe. "The federal government uses the Life Safety Code as a survey code, so we are trying to get the two codes to align.”

Not all hospital facility managers may be familiar with the ICC International Building Code as they may not be actively involved with the design of new facilities. But regardless, the ICC building codes do have a large impact on facilities since the local building officials work mostly out of the ICC building codes and less so out of the LSC. This leads to the construction of facilities that often do not fully comply with the LSC, particularly when it comes to suites of rooms. ICUs and emergency rooms are frequently designed and built too large, thereby making them noncompliant, and this lack of compliance is generally not discovered until an accreditation survey occurs. By then, any required change will be costly.

In many states, the state authority over healthcare construction frequently performs validation surveys on behalf of CMS. These state authorities are typically professional architects and engineers who have spent most of their careers working with the ICC building codes and tend to interpret the LSC slightly differently than CMS or The Joint Commission, says Beebe.

"I think the ICC advocacy project will make improvements in that area. It will put everyone on the same sheet of music so you don't have the conflicts that different codes may present. You won't get different opinions and different philosophies if the two codes are aligned,” says Beebe. "If everyone was working from basically the same text, then you're going to have less problems with states being overly conservative.”

ASHE has said that its advocacy efforts result in hospitals saving money. When asked to describe what changes could help hospitals save money, Beebe had plenty of examples to offer.

"Hospitals spend a lot of money in the installation and testing of fire and smoke dampers,” he says. "Most of the dampers are installed due to what is required by the building codes. The Life Safety Code has historically allowed smoke dampers at smoke barrier walls to be omitted in facilities that are fully protected with quick-response automatic sprinklers. In the ICC, that is not the case. If the two codes agreed on that subject alone, it would save hundreds of thousands of dollars each year in testing and repairs on unnecessary dampers. There are trade-offs, however. We're actually advocating to bite the bullet and make all existing hospitals sprinklered. It's a little-known fact that the current ICC Fire Code requires all hospitals to be sprinklered, including the existing hospitals.”

We all know that new healthcare construction is required to be sprinklered; that requirement has been in place since 1991. But with the adoption of the 2012 edition of the LSC, existing high-rise hospitals will be required to be sprinklered within 12 years of the LSC's adoption. So, perhaps the ASHE advocacy team is not that far off regarding the time it will take for existing hospitals to become fully sprinklered.

Other proposals for changes to the ICC building codes that the ASHE/ICC Ad Hoc Committee has been working on include:

Corridor width. Recommendations have been made that certain wheeled equipment be permitted in corridors provided there is a minimum of 5 feet of clear width remaining in the corridor, with the equipment being relocated during an emergency. This would be similar to what the 2012 edition of ?the LSC will allow.
Defend-in-place practice. The definition of defend-in-place techniques is supported by the ad hoc committee, to be placed in the ICC codes. This is an effort to provide clarity to building officials.
Visual and audible fire alarms. The committee believes that certain areas of the hospital, such as operating rooms, should not be required to have fire alarm occupant notification appliances, such as horns, chimes, and strobes, that could interrupt delicate surgery or patient care. The motive behind this proposal is to prevent patient harm.
Smoke control. A proposal is being considered by the ad hoc committee that would not require smoke dampers in HVAC systems that are fully ducted and where the facility is fully protected with automatic sprinklers.

These proposals will be voted on during ICC development hearings in Dallas, which are scheduled for April 29 to May 8. Beebe encourages ASHE members to get involved and help make these changes occur by attending the ICC meetings, submitting public comments on proposals, and generally supporting changes that will help hospitals save money while keeping patients and staff safe.

Editor's note: ASHE's advocacy team works hard to make changes to the codes and standards that regulate healthcare organizations so the codes have a scientific basis and are not based on opinion. This advocacy work is described as the lifeblood of what ASHE does for its members. In 2011 alone ASHE had a successful impact on NFPA 99, Health Care Facilities Code; the code will now be a risk-based approach rather than an occupancy-based one. This will make it easier for hospitals to determine requirements for new facilities, according to Beebe. All healthcare engineering professionals are encouraged to join ASHE and participate in their local chapter events.

CMS considers changes to humidity requirements

Sun, 01 Apr 2012 04:00:00 GMT

CMS considers changes to humidity requirements

According to information provided by the American Society of Healthcare Engineers (ASHE), CMS is considering changing the low-end limits on humidity requirements for operating rooms.

Currently the limit for humidity in operating rooms is 35% on the low end and 60% on the high end. Limiting the high-end humidity to 60% reduces infections and prevents mold and mildew. However, the low-end limit of 35% seems to have run the course of its usefulness. Originally, humidity was not allowed to drop below 35% because authorities feared a static electricity discharge could ignite flammable anesthetics. But since flammable anesthetics are no longer used or allowed in operating rooms, this limitation is no longer needed.

CMS is considering changing its policy to align with the American Society of Heating, Refrigeration and Air-Conditioning Engineers standards, which sets the low-end humidity at 20%.

Chad Beebe, AIA, SASHE, CHFM, CFPS, CBO, ASHE's director of codes and standards, has said that lowering the humidity to 20% in operating rooms would have no adverse effect on patients and could save hospitals thousands of dollars in operating costs and ventilation renovations.

Since CMS still requires compliance with the 2000 edition of the Life Safety Code® (LSC), hospitals must comply with the 1999 edition of NFPA 99, which has 35% as the low limit for humidity in operating rooms.

With the change to the 2012 edition of the LSC expected in the next 12-18 months, the new edition of NFPA 99, in which the humidity requirements have been removed, will be referenced, as those requirements were deemed out of the standard's scope. Because of this, a change in policy by CMS now would only have an effect for a short time until the 2012 edition is adopted.

Until a decision is made on this issue, hospitals may submit a waiver request to their state agency or accrediting organization if they feel complying with the 35% humidity requirements would present an unreasonable hardship. n

Dealing with fire barrier management

Sun, 01 Apr 2012 04:00:00 GMT

Dealing with fire barrier management

There seems to be a pattern of dealing with penetrations in fire-rated walls in healthcare organizations, and it is not a healthy one. With less staff and resources available for organizations to handle firestopping procedures correctly, a "caulk & walk” approach seems to be gaining momentum, and that worries industry experts.

The problem usually begins when the emphasis is incorrectly placed on the firestop product and not the system. "By themselves, firestop materials do not have a fire rating. The fire rating is achieved when the firestop material is used in an assembly,” notes Aedan Gleeson, DRI (UL), of Gleeson Powers, Inc., in Franklin, MA. "The emphasis should be on the firestop system. We're not installing materials, we're installing systems.”

Part of the problem may be attributed to the fact that firestop materials are available to poorly qualified individuals. Many firestop manufacturers offer on-site training sessions lasting two to four hours, which provides a certification to participants on the use of certain products. While this type of training can be a great introduction to the world of firestopping, participants can run into problems when they encounter a situation not discussed in their training. An example of this is the indiscriminate use of firestop material. Many healthcare organizations purchase large quantities of red firestop caulk and instruct their maintenance staff to seal the penetrations in fire-rated walls. But are they actually installing the product correctly and using it in an assembly approved for its purpose? In many cases they are not, and this can lead to improperly sealed fire barriers that may not resist smoke and fire as expected.

"The greatest challenge healthcare organizations have today is the lack of knowledge on how to use the firestop products. In many cases, they simply don't know what they are doing,” explains Gleeson.

For example, he says, do organizations know what system to install for:

Fire-retardant polypropylene piping?
Glass piping?
Insulated piping?
Conduits?
Copper piping?
Bus ducts?
Cable trays?
Heads of walls?
Curtain walls?
Construction joints?

"Do they understand what annular space is?” adds Gleeson.

Hospital maintenance technicians have been observed to use the same firestop material and method to seal all penetrations, regardless of what caused the penetration in the first place. They often do not take the time to research which UL assembly is required for certain types of penetrations. This leads to improperly sealed penetrations and exposes the organization to a potential citation from a surveyor or inspector. "What we often see in healthcare organizations is the attitude, ‘The bigger the blob, the better the job,' which is a very poor approach to fire barrier management,” says Gleeson.

One solution to this problem for healthcare organizations is to hire trained and qualified firestop contractors-not just any contractor, Gleeson notes, but an approved professional who has undergone rigorous training and examination, and received certification from a national independent standards organization, such as FM Approvals or UL.

One nonprofit organization called the Firestop Contractors International Association helped develop the special training with FM Approvals, which led to the FM 4991 standard for the approval of firestop contractors. According to FM Approvals, the purpose of FM 4991 is to improve the installation of firestop systems by examining and qualifying contractors involved in the installation of such systems. The annual audit includes an inspection in the field to ensure the contractors are not only installing the firestop system correctly, but are also providing the necessary training and resources for their employees. The field audit can be very effective as contractors do not know where and when an auditor will show up.

Additionally, UL offers its UL Qualified Firestop Contractor Program. Together, FM Approvals and UL developed programs that are now the industry's measure for all firestop contractors. Each FM Approved or UL Qualified company must have a designated responsible individual (DRI) who has exceptional knowledge of all aspects of firestopping, as demonstrated through a qualifying exam and maintaining continuing education in order to keep abreast of industry developments.

While the FM 4991 designation is voluntary and is not currently required by any code or standard, it demonstrates a high level of professionalism to the specialized field of firestop installers, which can be useful to facility managers when deciding on a company ?to hire.

If a facility manager decides to go with his or her own in-house staff, the manager has to rely on their own methods and means to be properly educated on the many aspects of firestop systems. As an example, a simple through-the-wall penetration created by a conduit in a fire-rated barrier must have the following criteria evaluated before a proper firestop system can be selected:

The life safety requirement of the barrier
The fire rating of the barrier
The annular space between the conduit and the wall
The size of the conduit

Once these factors are known, the facility manager must then select a UL system that meets all of these requirements. Common errors made when poorly trained individuals install firestop materials include not inserting the material far enough into the annular space between the conduit and the wall, or installing the material in a gap that is beyond its rated capacity. Facility managers who use in-house staff for firestop installation will most likely need to undergo an inspection process to ensure the product is installed correctly. A certain level of education and training is required just to be able to recognize a correct or incorrect application. For large hospitals with a budget to support their own in-house training and inspection process, this may not be a problem, but for small or medium-sized organizations struggling with available resources, it may make more sense to contract with an approved vendor for this service. The typical facility manager in smaller markets simply does not have the time or resources to perform this task well.

A successful fire barrier management program can reduce the frequency of recurring inspections on fire-rated barriers. Additional benefits may include:

An overall survey can be conducted to identify major issues before work begins
The appropriate firestop systems for specific situations will be installed properly
An above-ceiling permit program that manages the fire barriers effectively can be implemented

"The Joint Commission surveyors are getting smarter on fire barrier management and they are beginning to ask facility managers the UL reference number used on certain firestop installations,” says Gleeson.

The burden is now falling on the facility manager to prove that the firestop system used in a particular application is approved for that purpose. If the system looks suspicious, a surveyor may ask for documentation that it is correct. Without a certified label identifying the UL system used at each firestop system, the facility manager may have a difficult time proving its authenticity. Without the documentation, the surveyor may very well cite the hospital for noncompliance on managing its life safety systems.

Fire alarm technicians on hospital staff

Sun, 01 Apr 2012 04:00:00 GMT

Fire alarm technicians on hospital staff

One of the more important aspects of life safety in a hospital is the fire alarm system, where detection of fire and notification of the occupants and the local emergency response team of the alarm is a critical function. The industry in general has seen increased scrutiny of the testing and inspection process by accreditation organizations and state agencies. Facility managers have learned (or are in the process of learning) that having competent, knowledgeable people conducting the test is more important than ever. Given all this, why would a hospital consider making a change regarding the contractor or vendor that conducts its fire alarm testing?

"We found out the hard way not all vendors are as knowledgeable as necessary when it comes to understanding the testing requirements and frequencies required by NFPA 72,” says Chad Kruse, manager of construction & regulatory at The Nebraska Medical Center in Omaha. "The need for change is due to a lack of awareness on the contractor's part. We have had to review some basic testing protocols outlined by NFPA 72 with them to ensure the testing procedures and documentation meets the code requirements. We need to have better support if using a vendor to perform the testing.”

Finding qualified and trained contractors with experience working in a hospital is not as easy as one might think. The Nebraska Medical Center, for example, thought it was following all the correct procedures when it released a request for proposal (RFP) on fire alarm testing four years ago. It didn't turn out that way.

"Unfortunately, it was all based on the cost of testing. We put the RFP on the street and it explicitly said, ‘You will conduct all testing in accordance with NFPA 72,' ” says Kruse. "The hospital chose the low bidder and found the contractor wasn't entirely aware of the specific testing protocols for the hospital environment in order to meet the requirements identified in NFPA 72.”

Without a strong RFP or a procedure to follow up and monitor the service the contractor is providing, a hospital can quickly become noncompliant with the regulations for testing the fire alarm system and not be aware of it.

"Healthcare is a 24/7 operation and we cannot simply shut down or send everyone home just because the fire alarm system needs testing,” says Kruse. "We cannot allow the contractor to ring the bells and operate the strobes for three or four continuous hours so they can do their test. We have to find alternative ways to accomplish this without disrupting the patients and the operation of the hospital.”

There are actually two basic issues at stake here: finding qualified individuals to perform the test, and documenting of the test itself. If you have to wait weeks to get your reports, then you are susceptible to being found noncompliant. A Joint Commission representative has said if the reports are not in hand at the hospital during the survey, then the test did not happen.

"The documentation that the contractor provided was inconsistent and inconclusive at times,” says Kruse. "The contractor was found to be pre-stamping the quantities of devices tested on their paperwork prior to the test being performed. Their total number of devices being tested did not change from report to report, but I knew we had some renovation in the hospital and the quantity of devices was changing.”

Additionally, the contractors would come in and say they tested 50% of the devices in January and 50% of the devices in July, and those totals did not add up to the total device count, he explains.

"It was just basic simple stuff that caused us to pull our hair out, and we ended up babysitting these contractors and holding their hands to ensure they got it correct,” says Kruse. "At some point I said, ‘Look, won't it be easier to just take on the risk and hire our own appropriately certified and licensed individuals?' ”

The certification Kruse mentioned is a NFPA 72 requirement. Section 7-1.2.2 of the 1999 edition requires service personnel to be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems. Section 10.4.3 of the 2010 edition, which the new 2012 edition of the Life Safety Code® will reference, has similar requirements. Examples of qualifications include, but are not limited to, one or more of the following:

Factory trained and certified on the specific type and brand of system being serviced
Certified by a nationally recognized certification organization acceptable to the authority having jurisdiction, such as the National Institute for Certification in Engineering Technologies or the International Municipal Signal Association
Registered, licensed, or certified by a state or local authority to perform service on systems addressed within the scope of the LSC
Employed and qualified by an organization listed by a nationally recognized testing laboratory for the servicing of fire alarm systems

Whoever the hospital hires to perform service and testing on the fire alarm system must comply with one of the above requirements. Surveyors are now asking to see this certification when hospitals reveal they do their own testing and service.

The responsibility for a base list of devices in the fire alarm system falls squarely on the shoulders of the hospital, regardless of who provides the service for testing.

"We can't expect a vendor to know when we added or deleted devices in the hospital,” says Kruse. "We need to keep track of that ourselves and be able to hand that list to them each time they come into the building if we stay using a vendor. We're looking at an electronic format platform for fire alarm testing and will keep track of all devices.”

Other hospital facility managers have said that they ultimately save money by going with in-house fire alarm technicians rather than outsourcing the service. But Kruse is unsure that will be the case with his organization.

"I don't know yet as that is a big unknown for us since we are such a large campus. I don't have a good guess yet on how many bodies it will take to properly test our fire alarm system,” says Kruse. "Right now the current vendor we contract with conducts it with two people, and I know I am getting an inadequate product from them. I have the sense I could double or triple the testing crew fairly easily. Ultimately, we must do a better job of testing the fire alarm system throughout our campus. In our current arrangement, we are not providing the level of documentation in the manner we expect and we have to make a change.”

The common perception is that the quality of both the testing and the reports will improve if you control the technicians. But unexpected additional benefits come when the technicians are hospital employees and they have ownership and pride in their work. They have a vested interest in seeing the hospital succeed and do well, whereas a contract employee may not.

Knowledge is power, as wise people say. When you empower the facilities department with knowledge, such as having certified fire alarm technicians on staff, you then have additional pairs of eyes who are looking at all sorts of potential safety problems during their normal daily routine.

Whether a hospital hires its own technicians or contracts with a vendor to test and maintain the fire alarm system, one thing is for sure: The hospital needs to have someone who is knowledgeable on the NFPA 72 testing requirements to make sure whoever is performing the test is doing so correctly.

Bat colony leads to ?Immediate Threat to Life' decision

Sun, 01 Apr 2012 04:00:00 GMT

Bat colony leads to ‘Immediate Threat to Life' decision

A colony of Mexican free-tailed bats that found refuge in a void in a hospital wall led to that hospital being deemed as having an "Immediate Threat to Health or Safety” by The Joint Commission.

The FirstHealth Richmond Memorial Hospital in Rockingham, NC, was visited by The Joint Commission in mid-February after the agency received an anonymous tip on bats being inside the building. According to reports, Joint Commission surveyors found a bat in two patient rooms and some evidence of bat droppings, or guano, above the ceilings. The results of the accreditation organization's investigation led to its decision to declare the situation an "Immediate Threat.”

According to an article in the Richmond County Daily Journal, the hospital had been working with a professional bat removal service for about two weeks to get rid of the bats that were roosted inside the walls. After The Joint Commission declared the adverse decision, FirstHealth officials decided to close the hospital and conduct a thorough terminal cleaning of the 60-year-old, 99-bed facility to ensure all of the bats were removed from the building. Patients were either discharged or relocated to neighboring hospitals, with a total of 14 patients being transferred.

The emergency department remained open to receive walk-ins, but all patients brought by ambulances were diverted to other hospitals. Other than diagnostic services to support the emergency department, all other hospital services were discontinued. Patients with appointments were encouraged to either reschedule after the hospital reopened or schedule with other hospitals in the area.

Interestingly, the Richmond County Health Department conducted an inspection at the hospital the same day the Joint Commission surveyors were there, according to the article. The county health officials were aware of the hospital's efforts to get rid of the bats, and they tested a few bats that were caught inside the hospital for rabies. All tests came back negative. Since the county health officials did not find any guano and did not find any bats with rabies, they did not consider the situation a health risk.

The bats apparently roosted in a void in the building between the outer wall and the inner wall, but some of them found their way inside to the corridors and patient rooms. This is a prime example where voids need to be sealed not only for fire protection, but also for varmint infestation.

The professional bat removal service installed special one-way doors over the outdoor openings to the walls that allowed the bats to leave the building at night but prevented them from reentering. This variety of bat is a protected species and it is not allowed to be destroyed. The process of bat removal thus does not involve extermination, but rather encourages them to leave and not return.

An Immediate Threat to Life decision by The Joint Commission is a Preliminary Denial of Accreditation situation, and the organization has the right to appeal it before a decision of Denial of Accreditation is made. Usually, resolving the situation that caused the decision of "Immediate Threat” in the first place is reason enough to remove the Preliminary Denial of Accreditation decision.

This is just one example of events or factors that can trigger this process. Other situations that can trigger an Immediate Threat to Life decision include:

A compromised fire alarm system
A compromised sprinkler system
A compromised emergency power generator system
A compromised medical gas system
Compromised exits
Other situations of extreme danger

The hospital reopened for normal service five days after it closed, and the adverse decision of Preliminary Denial of Accreditation by The Joint Commission was changed to Contingent Accreditation.