Biggest Pitfalls and Best Practices: Life Safety

1. Biggest Pitfalls and Best Practices: Life Safety What Should I Know About the Life Safety Chapter? Healthcare Engineering Consultants

2. 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 Healthcare Engineering Consultants

3. Life Safety Compartmentation • 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 Healthcare Engineering Consultants

4. Life Safety Compartmentation • 1-hour FireBarrier Compartmentation Requirements • Extends from floor to deck above • Transfer air grilles protected by fire dampers • All penetrations sealed with appropriate materials • Doors are labeled 45-minute or 1-hour • Doors are self-closing • 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 Healthcare Engineering Consultants

5. Life Safety Compartmentation • 2-hour FireBarrier Compartmentation Requirements • Extends from floor to deck above • All duct penetrations protected by fire dampers • All penetrations sealed with appropriate materials • Doors are labeled 1.5 hour • Doors are self-closing • 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) Healthcare Engineering Consultants

6. Life Safety Compartmentation • 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) Healthcare Engineering Consultants

7. 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” Healthcare Engineering Consultants

8. Interim Life Safety Measures • The Interim Life Safety Measures Process Includes the Following Steps: • 1. Is an ILSM evaluation required? Y or N • If Yes, does the ILSM evaluation require the implementation of ILSM? Y or N • If Yes, which interim measures apply? • 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 Healthcare Engineering Consultants

9. Interim Life Safety Measures • 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” Healthcare Engineering Consultants

10. Interim Life Safety Measures Interim life safety measures evaluation exception for “routine work orders or superficial projects that do not impact life safety” Healthcare Engineering Consultants

11. Interim Life Safety Measures • 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 Healthcare Engineering Consultants

12. Interim Life Safety Measures 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 Healthcare Engineering Consultants

13. Interim Life Safety Measures 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. Healthcare Engineering Consultants

14. Interim Life Safety Measures • 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 Healthcare Engineering Consultants

15. Interim Life Safety Measures • 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 ofany 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 Healthcare Engineering Consultants

16. Interim Life Safety Measures (ILSM) Applicability Grid Example for Interim Life Safety Measures Interim Measure Ensuring Egress Barriers Notify Fire Dept Fire equipment Fire drills Operational LS Reduce combust. Fire watch Other Prohibit smoking Staff training Surveillance Deficiency Healthcare Engineering Consultants

17. Interim Life Safety Measures Example for Interim Life Safety Measures Chart 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 Healthcare Engineering Consultants

18. Interim Life Safety Measures 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! Healthcare Engineering Consultants

19. Interim Life Safety Measures Healthcare Engineering Consultants

20. Interim Life Safety Measures Healthcare Engineering Consultants

21. 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”? Healthcare Engineering Consultants

22. Fire Watch “Decision Grid” 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” Healthcare Engineering Consultants

23. 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 Healthcare Engineering Consultants

24. 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? Healthcare Engineering Consultants

25. 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 Healthcare Engineering Consultants

26. 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 Healthcare Engineering Consultants

27. Interim Utility System Measures 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 Healthcare Engineering Consultants

28. Life Safety Pitfalls Other Life Safety Deficiencies that are Likely to be Found Healthcare Engineering Consultants

29. Life Safety Deficiencies Additional Note: Joint Commission now accepts up to 6 inch projections above 40 inches from the floor Healthcare Engineering Consultants

30. Compartmentation Deficiencies What’s wrong with this seal? Healthcare Engineering Consultants

31. 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 entireassembly • 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 Healthcare Engineering Consultants

32. Egress Corridor Deficiencies What’s wrong with this picture? Healthcare Engineering Consultants

33. Egress Corridor Deficiencies 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) Healthcare Engineering Consultants

34. Egress Corridor Storage Additional Joint Commission Interpretations Egress corridors greater than 8 feet in width may be partitioned to provide alcove storage for computers, equipment Small (less than 50 square feet) dead-end corridors beyond the exit stairwell doorway may be used to store equipment 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!! Healthcare Engineering Consultants

35. Egress Corridor Storage Joint Commission Corridor Interpretations Staff Office Permitted Storage Space (if <50 sq ft) 8’ Width Egress Corridor Exit Stair Healthcare Engineering Consultants

36. Egress Corridor Storage Joint Commission Corridor Interpretations Staff Office 44” Permitted Storage Space (if <50 sq ft) 8’ Width Egress Corridor Exit Stair Healthcare Engineering Consultants

37. 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 Healthcare Engineering Consultants

38. FSES – Occupancy Risk Factors Healthcare Engineering Consultants

39. FSES – Safety Parameter Values Healthcare Engineering Consultants

40. FSES – Individual Safety Evaluations Healthcare Engineering Consultants

41. FSES – Fire Zone Equivalency Evaluation Healthcare Engineering Consultants

42. FSES – Fire Zone Equivalency Evaluation Healthcare Engineering Consultants

43. Biggest Pitfalls and Best Practices: Life Safety Questions? Healthcare Engineering Consultants