In Case of Fire, Resolve to Make a Plan in 2012

"In Case of Fire, Resolve to Make a Plan in 2012" 

This article first appeared in the February 2012 issue of Nashville Medical News.

By Robert Trotter, CBO, CFM, MCP


In a February 2009 report, the National Fire Protection Association (NFPA) identified that during 2003-2006, municipal fire departments responded to an estimated 3,750 structure fires in medical, mental health, and substance abuse facilities, annually. These fires resulted in one civilian death, 57 civilian injuries, and $26.9 million in direct property damage. While no amount of money can account for the loss of a loved one, the United States Consumer Product Safety Commission (CPSC) assigns a statistical value per life of $5 million; and according to its Injury Cost Model, the estimated cost of a fire-related injury is about $56,000 per incident. Therefore, the average total estimated cost of these healthcare facility fires was $34.2 million.

Every well-managed healthcare organization should have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary.


To read the entire article, please click here.

Temporary Electrical Wiring

Life Safety Tip from Bob Trotter, BS, MCP

Temporary Electrical Wiring
  
According to NFPA 70, National Electrical Code, 1999 edition temporary wiring is defined as “Approved wiring for power and lighting during a period of construction, remodeling, maintenance, repair, or demolition, and decorative lighting, carnival power and lighting, and similar purposes”. The NEC requires temporary wiring to be removed immediately upon completion of construction or purpose for which the wiring was installed.

Continuous Compliance - Maintaining a constant state of regulatory readiness

Continuous compliance - Maintaining a constant state of regulatory readiness

This article first appeared in the May 2011 issue of HFM Magazine.

By David L. Stymiest, P.E., CHFM, FASHE

Continuous compliance also has been called continuous survey readiness. It involves proactively maintaining a safe health care environment conducive to high-quality patient care. It essentially means having staff at all levels doing the right things for the right reasons because they understand those reasons.


Just about all accrediting agencies conduct unannounced surveys or inspections. Even when organizations think they know approximately when the next unannounced survey is due, there is the potential for random unannounced surveys or a for-cause survey. Thus, continuous survey readiness is crucial. Ongoing training and thorough staff involvement in compliance activities are essential because key managers might be unavailable when the surveyors arrive.


To read the entire article, please click here

Daily checks on Airborne Infectious Isolation (AII) rooms

CDC is often listed as the source of guidelines for daily checks on Airborne Infectious Isolation (AII) rooms.

The document with the CDC guidelines is "Centers for Disease Control and Prevention. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR 2005;54(No. RR-17)" and is at the following link: 

http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf

If you go to the CDC website and download the linked document, you will see the following wording in the right column on page 19 (PDF) or 17 (DOCUMENT PAGE #):

"Settings with AII Rooms

Health-care personnel settings with AII rooms should

• keep doors to AII rooms closed except when patients,

HCWs, or others must enter or exit the room (118);

• maintain enough AII rooms to provide airborne precautions

of all patients who have suspected or confirmed TB

disease. Estimate the number of AII rooms needed based

on the results of the risk assessment for the setting;

• monitor and record direction of airflow (i.e., negative pressure)

in the room on a daily basis, while the room is being

used for TB airborne precautions. Record results in an

electronic or readily retrievable document;"

Continuation not inserted here.  Refer to the referenced document for all guidelines.

 

Styrofoam Sound Barrier

Life Safety Tip from Bob Trotter, BS, MCP

Styrofoam Sound Barrier

The Styrofoam™ sheets applied to the walls of this mechanical room being use as a sound barrier must meet the interior wall and ceiling finish requirements of the 2000 edition of NFPA 101^®, Life Safety Code^®. For Health Care Occupancies Section 19.3.3.2 states the following: 

19.3.3.2  Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows: (1)   Existing materials — Class A or Class B. 

Exception:  In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6. 

It is expected that this type exposed product for this application will not meet the interior finish requirements.

Conflicting Exit Signs

Life Safety Tip from Bob Trotter, BS, MCP

Conflicting Exit Signs

This scenario exists at the bottom of an EXIT stair enclosure. The original EXIT sign did not indicate the direction of egress travel. Therefore the more modern EXIT sign was installed with the left Chevron indicating the direction of egress travel. However, the original sign should have been removed to eliminate the conflict that could pose risk to life safety.

Locker Rooms

Is a Locker Room considered a suite?

Smooth Start: Ensuring Emergency Power System Performance

Smooth Start
Ensuring emergency power system performance

This article first appeared in the February 2012 issue of HFM Magazine.

By David L. Stymiest, P.E., FASHE, CHFM

Like all other mission-critical systems, emergency power systems should be commissioned to attain the necessary operational reliability.

Emergency power system commissioning (Cx) can be considered a documented quality assurance program that finds and resolves potential emergency power system-related problems before patients are admitted and procedures are performed.

Emergency power system Cx is not the same as doing walk-throughs of the emergency power system and creating punch lists. Punch lists simply report what their preparers observed to be incorrect; whereas the Cx process can document that the installed equipment and systems are correct.

Click here to go to the article at the HFM Magazine website.

Fold-down Charting Stations in Corridors

What is The Joint Commission’s position on the use of springloaded, fold-down charting stations installed in corridors outside patient rooms? Are these a violation of the NFPA Life Safety Code, Section 7.1.10?

Preconstruction Risk Assessment

Is a preconstruction risk assessment required for every planned project? If not, how extensive must the construction project be before this is required? Does this apply to hospitals only, to ambulatory health care, or to other categories?

Life Safety Drawings

During a recent survey, a surveyor asked for our current LS drawings. We were unable to provide them, and the surveyor gave us a Requirement for Improvement (RFI), stating that we did not have a current Statement of Conditions (SOC). What is the link between current LS drawings and the SOC? What is required in a current set of LS drawings?

Emergency Lighting in Anesthetizing Locations

Does my organization need emergency lighting in anesthetizing locations? If so, where is this discussed?

Alcohol-based Hand Rub Volume

When calculating the volume of alcohol-based hand rub (ABHR) permitted in a single smoke compartment, do I need to include the amount in patient room dispensers?

CMS Recognizes Joint Commission Critical Access Hospital Accreditation

The Centers for Medicare & Medicaid Services (CMS) has again granted The Joint Commission deeming authority for the accreditation of critical access hospitals. The designation is effective November 21, 2011, through November 21, 2017, and means that critical access hospitals accredited by The Joint Commission may request to be “deemed” as meeting Medicare and Medicaid certification requirements.


From February 2012 EC News

New Joint Commission Partner Offers ISO Certification Option

The Joint Commission announced a new partnership with SGS Group that offers hospitals and critical access hospitals in the United States the option of pursuing both accreditation and certification with various International Organization for Standardization (ISO) and industry best-practice standards. Hospitals can select from a menu of certifications and tests, including ISO 9001 (quality management system), ISO 14001 (environmental management), ISO 27001 (information security), OHSAS 18001 (occupational health and safety), ISO 17025 (testing and calibration laboratories), and food safety testing and certification.


From February 2012 EC News

Joint Commission Issues Sentinel Event Alert on Health Care Worker Fatigue

The Joint Commission has issued a new Sentinel Event Alert: “Health care worker fatigue and patient safety.” The Alert urges greater attention to preventing fatigue among health care workers and suggests specific actions health care organizations can take to mitigate the risks. The Joint Commission Journal on Quality and Patient Safety reported that health care professionals who work long hours are at increased risk of injuring themselves on the job. The Alert is available on The Joint Commission website, at http://www.jointcommission.org/sea_issue_48.


From February 2012 EC News

Mesh Cubicle Curtains

What is the mesh requirement for cubicle curtains in hospitals?

Sprinkler Distance from Wall

What is the allowable distance a sprinkler head can be installed to a wall?