biggest pitfalls and best practices: life safety healthcare engineering consultants what should i...

Biggest Pitfalls and Best Practices: Life Safety

Healthcare Engineering Consultants

What Should I Know About

the Life Safety Chapter?

Life Safety Compartmentation


Life Safety Building Compartmentation Drawings

Blue – smoke barrier

Green – 1 hour fire wall (hazardous area)

Red – 2 hour fire wall

Note: The 2009 IBC now requires stencils to mark smoke and fire walls



Smoke Barrier Compartmentation Requirements

Extends from floor to deck above

Barrier penetrations protected by smoke dampers

Smoke dampers not required in ducted penetrations where QRS sprinklers are installed

All penetrations sealed with appropriate materials

Doors are labeled 20-minute or 1-3/4” solid core type

Doors are self-closing

Positive latching not required

½-hour smoke compartment must be at least two layers of ½” or more sheetrock (existing, one sheet on each side)

1-hour compartment for new construction, 5/8” on each side



1-hour Fire Barrier Compartmentation Requirements


Transfer air grilles protected by fire dampers


Doors are labeled 45-minute or 1-hour


Positive latching is required

1-hour smoke compartment must be at least two layers of 5/8” sheetrock (X-type, one layer on each side) or equivalent



2-hour Fire Barrier Compartmentation Requirements


All duct penetrations protected by fire dampers


Doors are labeled 1.5 hour


Positive latching is required

2-hour smoke compartment must be at least four layers of 5/8” sheetrock or equivalent (X-type, two layers on each side)



Smoke and Fire Door Requirements

Undercut to floor not more than ¾”

Vertical gap between doors not more than 1/8”

Warpage to frame less than ½”

All fire doors and frames must be labeled

Smoke doors must be labeled or 1-3/4” solid core construction

Doors must be self-closing

Positive latching is required for fire doors; not for smoke doors

Door tampering is not permitted; will alter the rating

Field installed protective plates >16” not permitted on fire doors

(exceptions exist for doors to hazardous rooms)

Interim Life Safety Measures


Interim Life Safety Measures Requirement

Standard LS.01.02.01 from the Joint Commission Accreditation Manual:

“The hospital protects occupants during periods when the Life Safety Code is not met or during periods of construction”



The Interim Life Safety Measures Process Includes the Following Steps:

1. Is an ILSM evaluation required? Y or N

2. If Yes, does the ILSM evaluation require the implementation of ILSM? Y or N

3. If Yes, which interim measures apply?

4. Implement and document the required measures

Note: An interim life safety measures policy must be written and address each of the four steps listed above



Step 1: Is an ILSM evaluation required?

The need for an interim life safety measure evaluation is normally required whenever there is a life safety deficiency that is found, or renovation or construction activities create life safety deficiencies.

Be sure to do an ILSM evaluation for PFI’s!

Include in the ILSM policy “exclusions” for evaluations, such as “routine work orders” or “superficial projects”



Example Interim Life Safety Measures Policy Purpose The purpose of this interim life safety measures (ILSM) policy is to address situations during periods of construction or renovation, or whenever Life Safety deficiencies exist and cannot be immediately corrected, so that an equivalent level of Life Safety is maintained. This policy also includes criteria for evaluating when and to what extent the hospital follows special, temporary measures to compensate for increased life safety risk. Policy This policy provides information and guidelines for evaluating and implementing interim life safety measures during times when a Life Safety deficiency is present due to construction or whenever an existing building deficiency is identified. Procedure When the hospital identifies Life Safety deficiencies during surveillance rounds, during periods of construction or renovation, or through other means, and the deficiency cannot be immediately corrected, the hospital performs an analysis to determine whether the implementation of interim life safety measures is necessary. This analysis is documented using the Interim Life Safety Applicability Form (ILSAF) attached to Appendix A of this policy. Completion of the ILSAF form is not required for routine work orders, or superficial projects that do not impact life safety in the hospital. If the completion of the ILSAF indicates that interim life safety measures are not required, then the completed form is maintained in a document file for reference purposes. If the ILSAF indicates that interim life safety measures are required to be implemented, then the Interim Life Safety Measures Chart (ILSMC) form is completed (refer to Appendix B) to determine which interim measures must be implemented and documented. The ILSMC form should be completed by referring to the following “Typical Triggers” for each of the possible interim measures listed below. Note: The following list of “Typical Triggers” are suggestions only and may be revised on the ILSAF form based on the judgment of hospital personnel. Measure 1: Notify the fire department, and initiate and document a fire watch. Typical Trigger Criteria: When the fire alarm or sprinkler system is out of service for more than 4 hours in a 24-hour period in an occupied building, as defined by the fire watch decision grid in Appendix C. Measure 2: Inspect exits in affected areas on a daily basis and document the inspection.

Interim life safety measures evaluation exception for “routine work orders or superficial projects that do not impact life safety”



Step 2: Are interim life safety measures necessary, based on the evaluation?

Interim life safety measure “trigger points” include the following:

Egress is compromised, and alternative exits are necessary

Compartmentation is breached,and is considered serious

Part or all of the fire detection or extinguishing system has been taken out of service

“Hot Work” is being performed

Large quantities of combustible materials are present

Other conditions determined by the organization


Interim Life Safety MeasuresAppendix A - Interim Life Safety Applicability Form

Description of Project or Deficiency: _________________________________________ ________________________________________________________________________ Location: ________________________________________________________________ Instructions: Determine whether any of the “ILSM Triggers” listed in the chart below apply to or will occur during this project. Description of ILSM Trigger

Applicable?

Hot work

Y N

Blocked exit

Y N

Alternate egress

Y N

Excessive combustible materials

Y N

Removal of part or all of the fire detection system

Y N

Removal of part or all of the extinguishing system

Y N

Significant breach of smoke or fire wall

Y N

Significant breach of smoke or fire door

Y N

Y N

Y N

Y N

If one or more of the ILSM triggers listed above are marked “Yes”, then interim life safety measures apply and must be evaluated using Appendix B, Interim Life Safety Measures Chart ______ ILSM measures do not apply ______ ILSM measures do apply _____________________________ _________________________ ______________ Signed Title Date

Check which “triggers” (if any) apply for the project

Add other “triggers, as desired

If none of the “triggers” are marked “Yes”, then no additional action is required



Step 3: Which interim life safety measures apply?

The use of an ILSM “applicability matrix” that helps to determine which interim measures apply is helpful. The matrix can either be “pre-filled” for specific conditions or left blank until the evaluation process occurs. The ILSM policy should describe how the interim measures are selected, based on criteria developed by the hospital.



Possible Interim Life Safety Measures Include:

Fire watch

Alternative exit signage

Daily inspection of exits

Temporary, but equivalent fire alarm and detection systems

Additional fire fighting equipment

Temporary, smoke-tight, noncombustible partitions

Increased surveillance of buildings, grounds and equipment

Storage, housekeeping and debris removal practices

Additional staff training for staff who use fire equipment



Possible Interim Life Safety Measures Include (continued):

Additional fire drills

Inspect and test temporary systems monthly

Additional staff training related to the interim measures

Additional training to compensate for impaired fire or building features

Note: Implementation of any or all of the interim life safety measures noted in the list above are based on criteria developed by the hospital and should be listed in the hospital interim life safety measures policy

Interim Life Safety Measures (ILSM)


Applicability Grid Example for Interim Life Safety Measures

Compromise egress X X X X X X

Breach compartmentation

X X X X X X X X X

Impair fire detection, alarm, suppression

X X X X X X X X

Hot work X X

Large quantities of combustibles

X X X X X X X X

Interim

Measure

Deficiency

En

su

rin

g

Eg

res

s

No

tify

Fir

e D

ep

t

Op

era

tio

na

l L

S

Ba

rrie

rs

Fir

e e

qu

ipm

en

t

Re

du

ce

co

mb

us

t.

Pro

hib

it s

mo

kin

g

Fir

e d

rill

s

Fir

e w

atc

h

Sta

ff t

rain

ing

Su

rve

illa

nc

e

Oth

er



Example for Interim Life Safety Measures Chart

Appendix B - Interim Life Safety Measures Chart

Description of Project or Deficiency: _________________________________________ ________________________________________________________________________ Location: ________________________________________________________________ Instructions: Based on the project or deficiency described above, determine and document which of the following interim life safety measures apply in the chart below. Description of Interim Measure

Applicable?

Fire watch (see Appendix C)

Y N

Signage signifying alternative exits

Y N

Daily inspections in affected area

Y N

Temporary and equivalent fire alarm and detection systems

Y N

Additional portable fire extinguishers

Y N

Temporary construction partitions (non- or limited combustibility)

Y N

Increased surveillance of buildings, grounds or equipment

Y N

Additional storage, housekeeping and debris removal

Y N

Additional staff training for portable fire extinguishers

Y N

Additional fire drills

Y N

Monthly tests and inspections of temporary systems

Y N

Additional staff training for construction hazards, temporary measures

Y N

Additional staff training for impaired fire safety features

Y N

Additional comments related to required measures: ____________________________ ______________________________________________________________________ _____________________________ _________________________ ______________ Signed Title Date

One or more of the interim measures listed on the chart may be selected, based on the scope of the project and the type of deficiency that exists



Step 4: Implement and document the required measures

Whichever interim measures are selected must be implemented and documented

Remember: Failure to implement or document interim life safety measures, when required, can result Conditional Accreditation from the Joint Commission!

Fire Watch Requirements


LS.01.02.01: EP 1

“The hospital notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm or sprinkler system is out of service more than 4 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented”

Question: What constitutes when “a fire alarm or sprinkler system is out of service”?

Fire Watch “Decision Grid”


Appendix C – Fire Watch Decision Grid

Description of Project or Deficiency: _________________________________________ ________________________________________________________________________ Location of Project or Deficiency: ____________________________________________ Fire Watch Notification: ______ Fire Department ______ Other Responders ______ Insurance Company ______ Internal Hospital Staff ______ Other Instructions: Based on the “Out of Service” description listed in the chart below, the requirement for a fire watch is indicated. Circle each “Yes” below, as applicable. Description of Fire Alarm or Sprinkler System “Out of Service” Condition

Fire Watch Required?

Multiple fire alarm or sprinkler system components out-of- service for less than 4 hours in a 24-hour period

No

Fewer than 6 smoke detectors in the same area out-of- service for more than 4 hours in a 24-hour period

No

Extinguishing system in less than a single smoke compartment out-of-service for more than 4 hours in a 24-hour period

No

Fire alarm system in “bypass” mode due to testing

No

More than 5 smoke detectors in the same area out-of-service for more than 4 hours in a 24-hour period

Yes

Extinguishing system in more than a single smoke compartment out-of-service for more than 4 hours in a 24-hour period

Yes

Any combination of fire detection and extinguishing devices out of service > 4 hours in a 24-hour period at the same time

Yes

Failure of the fire alarm annunciator panel (any time period)

Yes

Failure of the entire fire detection system (any time period)

Yes

Failure of the entire extinguishing system (any time period)

Yes

Failure of the fire pump (any time period)

Yes

Y N

Y N

_____________________________ _________________________ ______________ Signed Title Date

The requirement for a fire watch is determined by the hospital staff. NFPA 101, section A.9.6.1.6 states: “it is not the intent of the Code to require notification of the AHJ for a single non-operating device or appliance”

Other “Interim Measures”


What about interim measures for Utility Systems?

Interim fire system measures (IFSM)

Example: Changing out the fire pump (also ILSM)

Interim emergency power measures (IEPM)

Example: Changing the oil and filter in an emergency

generator

Interim medical gas system measures (IMGM)

Example: Installing a new oxygen source valve

Interim Fire System Measures (IFSM)


What about interim measures for Fire Systems?

Example: Replacing the fire pump

Possible Interim Measures:

1. Notify staff, local fire department and insurance company

2. Provide for back-up pump, if possible

3. Implement fire watch throughout affected areas

4. Obtain additional portable fire extinguishers

5. Perform replacement at non-critical times

6. Other?

Interim Emergency Power Measures


What about interim measures for Emergency Power?

Example: Changing the generator oil and filter

Possible interim measures:

1. Obtain back-up generator (not usually necessary)

2. Notify staff in critically affected areas (ICU, OR, NICU, etc.)

3. Perform service during “less critical” times

4. Verify that back-up, battery-operated equipment is functional

5. Remind staff of emergency procedures for “no power”

6. Review procedures for actual normal power failure with service personnel

Interim Medical Gas Measures


What about interim measures for Medical Gas and Vacuum Systems?

Example: Installing a new oxygen source valve

Possible interim measures:

1. Obtain truck with liquid oxygen tank and vaporizer to connect to emergency low pressure inlet

2. Notify staff in affected areas

3. Obtain additional “H” cylinders for back-feed, if necessary

4. Perform installation during less critical time periods

5. Verify that critical patient areas have adequate oxygen tanks

Interim Utility System Measures


Interim Utility System Measures Project Number: _________________ Date: ____________________ Affected System: Fire System: _____ Emergency Power _____ Medical Gas: _____ Description of Project: ______________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Interim Measures Required: _____ Affected staff notified Comments: ______________________________________ _____ Additional Equipment Required Specify: _________________________________ _____ Back-up Procedures in Place Specify: ___________________________________ _____ Emergency Procedures Reviewed Comments: ____________________________ _____ Other: ______________________________________________________________ _____ Other: ______________________________________________________________ _____ Other: ______________________________________________________________ Additional Comments: ______________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Date Project Completed: ___________________ Reviewed By: ____________________

Describe what actions the project requires

Be sure to notify the staff and departments that will be affected, and which special procedures are necessary

Maintain this and other related documentation in the project file

Other Life Safety Deficiencies that are

Likely to be Found


Life Safety Pitfalls


Life Safety Deficiencies

Minimum Corridor Aisle and Ramp Width

Exit Access in:

Minimum Clear Width

New hospitals and nursing homes

8 feet

New limited care facilities and psychiatric hospitals

6 feet

Patient Areas in Existing Facilities

48 inches

Non-Patient Areas (new and existing)

44 inches

Note: 3.5 inch projections at and below handrail height is permitted on each side

Additional Note: Joint Commission now accepts up to 6 inch projections above 40 inches from the floor

Compartmentation Deficiencies


What’s wrong with this seal?


Compartmentation Deficiencies

Repair of Smoke and Fire Wall Penetrations

Polyurethane foam should never be used as a sealant!

Intumescent materials should not only be tested, but pass the tests!

Smoke and fire ratings apply to the entire assembly

Smoke barriers (1/2 hour) need at least 1/2” sheetrock (each side)

1-hour fire barriers require at least 1-1/4” of sheetrock (2 layers)

2-hour fire barriers require at least 2-1/2” of sheetrock (4 layers)

Insulation or mineral wool requires intumescent capping

Use the manufacturer applications book for proper installation

Unusual applications require an “engineering judgment”

The use of labels describing the seal is recommended


Egress Corridor Deficiencies

What’s wrong with this picture?


Corridor Interpretations

Life Safety Code: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency (7.1.10.1)

CMS and Joint Commission: An 8-foot clear corridor width must be maintained . . . CMS permits items to be in the corridor for temporary use of one half-hour or less . . . Both agencies agreed that computers on wheels (COW’s) may not be plugged in to recharge while in a corridor (Mills, Zimmerman)

Joint Commission: Carts on wheels permitted in the corridor when in use; COW’s permitted when charting being performed; otherwise store in clean utility rooms or patient rooms (EC News, 2/07)

Egress Corridor Deficiencies


Additional Joint Commission Interpretations

1. Egress corridors greater than 8 feet in width may be partitioned to provide alcove storage for computers, equipment

2. Small (less than 50 square feet) dead-end corridors beyond the exit stairwell doorway may be used to store equipment

3. Where only offices exist in an egress corridor beyond an exit stairwell door, only 44 inches of clearance is required to be maintained in the corridor!

Important Note: Although these interpretations were provided by George Mills (Joint Commission Senior Engineer) at the 2008 ASHE Annual Conference, local AHJ’s may not permit these exceptions! Be careful!!

Egress Corridor Storage


Joint Commission Corridor Interpretations


8’ Width Egress Corridor

Staff Office

Exit Stair

Permitted Storage Space

(if <50 sq ft)


Joint Commission Corridor Interpretations


8’ Width Egress Corridor

Staff Office

Exit Stair

Permitted Storage Space (if <50 sq ft)

44”


Request for Life Safety Code Equivalency

Traditional Procedure:

Identify the deficiency (reference the LSC, state the intent)

Propose an alternate solution (provide explanation, drawings, cost, commitment of funds and timetable)

Get certification from PE, AIA, etc. and submit to JCAHO

FSES Procedure:

Survey facility to determine deficiencies

Provide BBI for building in which equivalency is requested

Perform FSES evaluation for fire/ smoke zone in question

Determine if equivalent condition exists

Submit PFI with actions, cost, commitment of funds, timetable, and FSES worksheet to the Joint Commission


FSES – Occupancy Risk Factors


FSES – Safety Parameter Values


FSES – Individual Safety Evaluations


FSES – Fire Zone Equivalency Evaluation

Biggest Pitfalls and Best Practices: Life Safety

Questions?


biggest pitfalls and best practices: life safety healthcare engineering consultants what should i...

Documents

life safety slide

life safety code

life safety deficiencies

life safety deficiency

life safety chapter

interim measures

required measures

hour doors