Life Safety Essentials: Smoke Detector Near HVAC Diffuser

Learning Objective: To identify if a smoke detector is too close to an HVAC diffuser.

By Robert Trotter, CBO, CFM, MCP - Manager, Sr. Life Safety Specialist
  

Smoke detectors are an integral component of a fire alarm and detection system. Placement of detectors and other devices are essential to proper operation of the system. Smoke detectors installed too close to HVAC diffusers may cause nuisance alarms, and more importantly fail to function or cause a delay in alarm transmission and occupant notification. Most people believe detectors are required to be installed at least 3 ft from an HVAC diffuser. Smoke detectors are to be installed out of the air stream. To correct the deficiency detectors can be relocated or the diffuser can be changed to distribute a different air stream.

Protrusions in Egress Corridor

We just opened a new Emergency Care there are devices mounted in the corridors with a large 3" conduit with a half inch wire coming out of the hole.  We received a work order to install protection devices around the four x-ray control panels located in the hallway outside the radiology rooms in the new EC. These units protrude 5-8 inches into the hallways and any protection we install will end up being an additional 2-3 inches. This may cause trouble during an inspection for protruding too far into an egress corridor. Do you have any suggestions that will help keep us in compliance?

Humidity in Operating Rooms

Does the ANSE/ASHRAE/ASHE Standard #170, which reduced the minimum relative humidity requirement for operating rooms to 20%, apply to existing operating rooms as well as new operating rooms? 

Self-Closing Devices

In areas with sprinkler systems, do patient room doors or corridor doors need to have closers? 

Life Safety Essentials: Fire Blankets

Learning Objective: To understand the use and application of fire blankets in laboratories.

By Robert Trotter, CBO, CFM, MCP - Manager, Sr. Life Safety Specialist

In almost every hospital laboratory there is a fire blanket in a cabinet or container similar to the one pictured. During one survey the question was asked: where is the requirement for a fire blanket in a laboratory? There is no specific requirement for fire blankets in laboratories. However, the 2000 edition of NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals Section 4.6.3.2* does require “Procedures for extinguishing clothing fires shall be established”. Fire blankets should be used only when immediately at hand. It should be recognized that rolling on the floor not only smothers the fire but also helps to keep flames out of the victim’s face, reducing inhalation of smoke. If procedures are not in place, fire blankets should be removed or such procedure established.

Taking Care of Business – How Hospital Electrical Shutdowns Can Facilitate Emergency Management

By David L. Stymiest, P.E., CHFM, FASHE (at ASHE 45th Annual Conference, July 2008)


ABSTRACT
Managing hospital electrical shutdowns is more important than ever in light of increasing concern about the impact electrical power outages can have on hospital operations. Electrical distribution equipment requires regular repair or maintenance, yet often this critical work is deferred because it is too difficult for the hospital facility director to get clinical permission to turn off the power. If equipment is not regularly shut down for maintenance, unexpected failures will be more probable, and then it is too late to train the clinicians in this aspect of the Environment of Care. This management monograph demonstrates the credible need, plans, communicates, trains clinicians, and provides guidance for conducting safe, effective building-wide or multiple building electrical shutdowns, based on specific case studies and lessons learned at other hospitals. It also discusses the interrelationships between proactive shutdown management and emergency management concepts.

INTRODUCTION
Emergency Management is not just a paper exercise. New regulations require an all-hazards approach, including preparing for power outages. Many hospitals still do not maintain their electrical power systems because they will not turn them off. Why the dichotomy? Why does our unwillingness to deal with this necessity put our patients at increased risk while we plan for a result we are unwittingly helping to bring about?

An electrical "shutdown" as described here is a pre-planned and scheduled partial or full electrical distribution system outage necessary to satisfy the needs for electrical equipment modification, replacement, upgrade, maintenance, and/or repairs; support staff training and clinical unit training. Shutdowns can meet needs in all of these areas that may not be met any other way.

Read entire article here: Taking Care of Business

Extension of a PFI

What is the process to extend the projected completion date of a PFI and what are the consequences if the extension is not approved?

Health Care Energy Management Benchmarking

By David L. Stymiest, P.E., CHFM, FASHE (at ASHE 47th Annual Conference, July 2010)

Abstract
This paper includes energy benchmarking uses, metrics, tools, operational differences and efficiencies, early benchmarking pitfalls, fuel cost variances, dashboard reporting, multi-year trending analyses, load profiling, utility rates; weather and campus growth impacts on both energy index and utility index, similar/dissimilar facilities, and the pros and cons of the US-DOE CBECS databases. Also included are load factors, peak demand charges, energy intensity, utility programs, supply/demand side management, comparing uses, buildings, campuses and systems.
  
Much utility/energy usage and cost analysis is based upon locally available information without
input from others. When outside input is sought for benchmarking purposes, the ability to
compare apples with apples is often severely limited by assumptions and misinformation.
  
This paper discusses approaches that work well as well as approaches that don’t work very well.
  
Examples include actual benchmarking spreadsheet tools and management presentation
documents used in health care facility utility budget discussions, with an emphasis on effectively
presenting the results of the benchmarking activities.
  
Read entire article here: Health Care Energy Management Benchmarking

Fire Alarm Signal

Does the provision in LSC 18.7.1.2 regarding “transmission of a fire alarm signal” mean the signal to the Emergency Forces per 9.6.4 which allows the use of one of the following means accepted by the AHJ in accordance with NFPA 72:  (1) Auxiliary alarm system  (2) Central station connection  (3) Proprietary system  (4) Remote station connection; or is it only referring to the “transmission of a fire alarm signal” which can be limited only to the notification of occupants, such as that allowed by a “coded announcement”? 

What about Day 2? Transitioning from Construction to Operations

By David L. Stymiest, P.E., CHFM, FASHE (at ASHE 46th Annual Conference, August 2009)
  

Introduction
Construction projects have standard approaches and processes. Facility operations, management and compliance also have standard approaches and processes. Many hospitals lack a solid process of transitioning from a construction project to operations and compliance. This affects the staff’s ability to manage systems and puts the hospital at risk of noncompliance with codes, standards, rules and regulations. This paper is intended to bridge the gap between construction and operations, providing an overview of the facility operations, management, and environment of care (EC) compliance issues and needs for Day 2 – the day after a facility opens.
  
Changing activation and turnover approaches
Early approaches to facility activation and turnover focused on the logistics of acquiring and installing new equipment and furniture, along with the facility to house it. When the facility neared completion, teams would start scheduling the building turnover sequences - department moves and patient moves.
  
Current thinking about new facilities involves much more than what must fit into it and how the facility will work. Now healthcare administrators might decide that the new facility must resolve concerns about existing service delivery shortcomings. Furthermore, they want the new facility to incorporate best practice operational models.
  
Read entire article here: What about Day 2? 

Eye Wash Stations

A hospital has Gus Stations in several areas and uses Cidex OPA in them.  Is an Eye Wash Station required to be in the area? 

Powering Down: An orderly process for switching off hospital electrical equipment

By David L. Stymiest, P.E., CHFM, FASHE (in Hospital Engineering Trends Sept/Oct 2004)
  

An electrical shutdown is a carefully managed process whereby electrical equipment is switched off for various reasons, including crucial maintenance, training, expansion and repair; and then turned back on again with minimal impact to patients.
  
Electrical shutdowns can be performed safely and hospitals can gain added benefits from their electrical shutdowns if they also use them to train clinical and support staff in how to deal with power outages. Hospitals taking this approach are continuously improving their environment of care.
  
The right time?
Hospitals need to plan electrical shutdowns whenever modifications must be made to the equipment. Industry experts will tell you that working “hot” is never a good idea if there is any other way. A well-planned shutdown is that other way, and it is required in many instances. For example, it should be planned shortly after completion of construction/renovation (C/R) activity in the vicinity of the electrical equipment, even if the electrical system itself is new.

Read entire article here: Powering Down

Managing Hospital Emergency Power Programmes

By David L. Stymiest, P.E., CHFM, FASHE (in Business Briefing: Hospital Engineering & Facilities Management 2004 for the International Federation of Hospital Engineering (IFHE), London UK)

A hospital can have a simple or complex emergency power supply system (EPSS) but ensuring that the system continues contributing to safe and effective patient care with today’s challenges is rarely simple. Complexity is introduced because the EPSS powers other hospital systems such as the clinical, mechanical, vertical transportation and fire management systems. The hospital engineer must also respond to new requirements that affect the EPSS, including requirements for utility management, emergency management, patient safety, continuous quality improvement and staff education. All of these interrelationships cause complexity.

An EPSS includes generator sets, generator set auxiliary systems such as cooling, combustion air, fuel oil and starting systems, paralleling switchgear, automatic transfer switches, distribution panels, lighting and power panel boards, feeders and branch circuits. Some facilities that do not have EPSSs may have a stored-energy EPSS (SEPSS). Facilities can also have an uninterruptible power supply (UPS).

When the normal power fails, all normal loads are dead. All emergency loads experience a short loss of power unless they are backed up by an SEPSS or UPS. The hospital’s clinical staff must know how to deal with this condition. The monthly load testing simulates this experience as illustrated in Figure 1, although the length of time without voltage during a test is likely to be less than it would be during an actual outage. A proactive EPSS management programme will use the lessons learned from the monthly load testing, along with regular normal power shutdowns, to train the clinical staff to expect and then manage this critical element of the environment of care.

Read entire article here: Managing Hospital Emergency Power Programmes

Compliance News: Increased Surveillance for ILSM's

By Robert Trotter, CBO, CFM, MCP



The Joint Commission’s 2010 Hospital Accreditation Standards for Life Safety describes the Interim Life Safety Measure (ILSM) for increased surveillance. LS.01.02.01 Element of Performance 8 states the following:

When the hospital identifies Life Safety Code (LSC) deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Increases surveillance of buildings, grounds, and equipment,  giving special attention to construction areas and storage, excavation, and field offices. The need for increased surveillance is based upon criteria in the hospital's Interim Life Safety Measure (ILSM) policy. (See also LS.01.01.01, EP 3)

In the example pictured, increased surveillance would have identified construction materials being improperly stored near electrical service equipment.

Compliance News: Determining Occupant Load

By Robert Trotter, CBO, CFM, MCP

The occupant load, in number of persons for whom means of egress and other provisions are required, is determined on the basis of the occupant load factors of Table 7.3.1.2 of the 2000 edition of NFPA 101®, Life Safety Code®  that are characteristic of the use of the space or are to be determined as the maximum probable population of the space under consideration, whichever is greater. For example: A healthcare occupancy has a floor of 30,000 square feet of patient sleeping rooms. Therefore, divide 30,000 by 120 which gives a minimum occupant load of 250 persons. These are minimum occupant loads for which egress capacity must be provided. The actual occupant load may exceed this if egress capacity is sized accordingly. Remember, these factors represent the use of the area being calculated not the occupancy classification. A healthcare occupancy may have any of these uses on the same floor without fire resistance rated separation.

Compliance News: What are Supervisory Signal Devices?

By Dean Samet, CHSP



The Joint Commission Standard EC.02.03.05, EP1, states that “At least quarterly, the hospital tests supervisory signal devices (except valve tamper switches). The completion date of the tests is documented.” What systems contain these supervisory signal devices and what is their function? Actually, it is the automatic sprinkler systems as explained in the NFPA Life Safety Code® and National Fire Alarm Code® and as defined below.

Ref. 2000 NFPA 101® Life Safety Code®
Section 9.7 Automatic Sprinklers and Other Extinguishing Equipment

9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72®, National Fire Alarm Code®, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. System components and parameters that shall be monitored shall include, but shall not be limited to:    

Compliance News: TJC Adopts the 2010 Guidelines

               
By Dean Samet, CHSP



The Joint Commission announced in their December, 2010 Environment of Care News that effective January 1, 2011, they will be referencing the 2010 edition of the Guidelines for Design and Construction of Health Care Facilities for new, altered, or renovated space design criteria. The 2010 TJC accreditation manual referenced the 2001 AIA Guidelines for Design and Construction of Health Care Facilities.
   
According to TJC, the 2010 Guidelines contain several new and revised sections, including but not limited to the following:   

Compliance News: TJC's Speak Up Program Improving Patient Safety

By Dean Samet, CHSP


Direct from The Joint Commission web site is information on how your patients can contribute to their own safety and help reduce your numbers in health care errors. 
      
In March of 2002, The Joint Commission (TJC), together with the Centers for Medicare and Medicaid Services (CMS), launched a national campaign to urge patients to take a role in preventing health care errors by becoming informed, active, and involved in their own health care and participants on the health care team. The campaign features brochures and posters which address a variety of patient safety topics. Speak Up™ encourages the public to:

5-Year Obstruction Inspection

What are the procedure and proper documentation for the NFPA 25 5-Year Obstruction Inspection?  Does it need to be done?

Planning for Power Failures

By David L. Stymiest, P.E., CHFM, FASHE (at ASHE 44th Annual Conference, July 2007)
  

Introduction
Without power healthcare facilities are extremely vulnerable, especially if it is for an extended period of  time. Every healthcare facility needs to have a plan in place and be prepared since there is rarely a warning before loss of power except in cases where a slow-moving hurricane or similar natural disaster is approaching.

The purpose of this paper is to offer recommendations and examples of effective power failure planning concepts, including gap analyses, emergency power risk assessments, commentary and recommendations on power failure vulnerability analyses, and other tools to improve readiness for power failures.

This paper also offers several dozen emergency management tracer-type questions on power failures to enable a healthcare organization to test its own readiness. These sample tracer-type questions address the issues discussed in this paper and in the following statement.
  
Read entire article here: Planning for Power Failures

Damper Inspections

What is the annual requirement for testing electromagnetic dampers? 

Med Gas Storage Room Ventilation

How should medical gas storage rooms containing more than 3000 cubic feet of compressed gas be ventilated?