Health Care
Some of the biggest proposed changes to the 2012 edition of the Life Safety Code focus on health care occupancies
NFPA Journal®, January/February 2011
By James K. Lathrop + Jennifer Frecker
A number of major changes have been proposed for the 2012 edition of NFPA 101®, Life Safety Code®, and many of those proposals have broad implications for the health care industry, from hospitals to nursing homes.
These include simplification of the "separated use" provisions that would make the code easier to understand and use, resulting in more situations where the added requirements for mixed occupancy would not have to be applied; an assortment of issues related to corridors, including projections, fixed furniture, and additional criteria for items in use in corridors; changes in long-term care facilities for the use of kitchens and the allowance of more decorations in resident rooms; and a variety of issues related to suites, including intermediate rooms and egress.
These are just some of the changes proposed for Chapters 18 and 19, which cover health care occupancies. There are also proposed changes for the code’s core chapters that would affect health care occupancies, such as new provisions for normally unoccupied areas. Items that have a Certified Amending Motion, based on a submitted Notice of Intent to Make A Motion, will be discussed during the Technical Reports Session at the 2011 NFPA Conference & Expo, which will be held in Boston June 12–15.
Most of these proposed changes, like the bulk of the changes made to the code since 2000, make it not only easier to use, but also easier for users to comply with, since it offers more options for compliance. That’s not only a plus for the health care industry, but for all of us who have to pay for health care, since the majority of the changes will result in reduced costs for construction and maintenance of health care facilities. Much of the code’s evolution is being driven by changes in how health care is delivered, such as the movement toward a more homelike setting for patients in a range of health care occupancies, and by shifts in who requires care, such as the large population of aging baby boomers that will require more care more frequently in years to come.
Observers of, and participants in, this code evolution process stress that changes that make the code easier to use don’t reduce safety for patients or for health care workers. In fact, it can be argued that an easier-to-use code results in safer buildings, since onerous issues that provided little if any life safety have been eliminated, allowing surveyors to focus on more important issues, and because changes have often come with offsetting requirements such as additional sprinkler protection or smoke detection. More options have also been added to the code to obtain the same, or even better, levels of safety. For example, the revisions for suites, which primarily started with the 2006 edition of the code with later improvements in the 2009 edition, offer significant improvements, allowing flexibility while improving life safety.
Despite the changes and improvements made to the code over the past decade, key health care funding and regulatory bodies continue to use the 2000 Life Safety Code as their reference code. The Centers for Medicare and Medicaid Services (CMS), part of the U.S. Department of Health and Human Services, mandates that health care facilities must comply with the 2000 edition of NFPA 101 to receive Medicare or Medicaid funds. Similarly, The Joint Commission (TJC), the independent organization that certifies and accredits more than 18,000 health care programs and organizations nationwide, mandates compliance with the 2000 edition of the Life Safety Code.
While the broad application of the Life Safety Code to health care occupancies has helped reduce the number of fires and fatalities over the past 40 years, the use of a document more than a decade old poses potential problems. Three subsequent editions of NFPA 101 have arrived since 2000, and numerous wide-ranging changes and updates have been made to the code during that period. The 2000 edition of NFPA 101, for example, references outdated editions of important standards, including the 1999 edition of NFPA 13, Installation of Sprinkler Systems. For someone to design or install a sprinkler system to such an outdated edition would be considered negligent by many.
The 2000 edition does not recognize newer philosophies both in fire protection and in health care. Newer editions of the code give more credit to smoke detection in suites and corridors, recognize the need to mount items such as computers on corridor walls, and recognize something as simple as allowing residents of long-term care facilities to be able to put their grandchildren’s artwork on the walls of their rooms.
Additional changes since 2000 address the difference between fire-resistance-rated and fire-protection-rated glazing for windows and doors; dramatically improve the way we handle penetrations of fire-resistance-rated walls and floors and joints in such walls; clarify that audible and visible fire alarm notification devices are not required in exit stairs and elevators; continue to improve the provisions for access-controlled egress doors and various levels of door locking for security purposes; significantly change Chapter 10 to regulate new materials, such as polypropylene and high-density polyethylene, used as interior finishes; make provisions to allow horizontal sliding doors without a breakaway feature — whereby the door panels swing out to provide a large opening for fast removal of patients or equipment — for rooms with fewer than 10 occupants; and define major and minor renovations, clearly identifying what must be done for minor renovations in nonsprinklered areas. Taken together, the newer editions of the code recognize today’s issues in a health care facility and permit more ease in operating health care occupancies and more cost savings in constructing and maintaining health care facilities.
Major health care organizations, including the American Society for Healthcare Engineering, which is part of the American Hospital Association, and the American Health Care Association (AHCA) say that the 2012 edition of NFPA 101 would have a significant benefit for the safety of patients and occupants of health care facilities, as well as the industry overall. ASHE will push CMS to adopt the 2009 edition of NFPA 101 as soon as possible and to adopt the 2012 edition when it is issued. AHCA believes adoption of the 2009 edition would only delay adoption of the 2012 edition of the Life Safety Code. So far, all of the proposed actions on these changes have been upheld by the Technical Committee on Health Care Occupancies.
Culture-change + beyond
Among the changes likely to generate discussion is the proposal to exempt sprinklers from very small closets in hospitals, spaces that are currently required to be sprinkler-protected in a sprinklered building. A task group consisting of representatives of NFPA 101, NFPA 13, and NFPA 99, Health Care Facilities, developed a proposal to exempt sprinkler protection from clothes closets of 6 square feet (0.5 square meters) or less in hospitals. This is due to the fact that it is becoming increasingly difficult for designers, facility management, and inspectors to distinguish between a closet, a wardrobe, or a cabinet in a hospital patient room due to new styles of cabinetry and the increased use of different types of storage arrangements. Currently, cabinets are not required to have sprinklers, but closets are. The position of the NFPA 99 and NFPA 101 representatives is that most cabinets exhibit a fuel load similar to a typical clothes closet in a hospital, and, as a result, they should have the same exemption.
Another issue that involves sprinklers is a proposed change to clarify that residential sprinklers may be used in patient sleeping rooms. The Life Safety Code has offered the use of residential sprinklers or quick-response sprinklers since 1991 when the code first mandated sprinklers in all new health care facilities. However, there have recently been questions as to how it works in conjunction with NFPA 13, which allows residential sprinklers in nursing home sleeping rooms but not in hospitals. Based on fuel load and room arrangement, the NFPA Technical Committee on Health Care Occupancies believes that the use of residential sprinklers in these rooms is consistent with the fuel loads that these sprinklers are designed to control. Since it is currently not recognized by NFPA 13, this will probably be controversial. Sprinkler industry representatives submitted comments opposing the change, but the comments were rejected.
Another issue generating discussion is a series of proposed changes to allow certain items to be placed in corridors. The changes attempt to address items that are commonly found in corridors while ensuring that at least 5 feet (1.5 meters) of corridor width is kept clear. The modifications that have been considered look at the use of certain wheeled equipment that is essential to the everyday operation of health care occupancies, as well as use of certain furnishings in long-term care environments. Most of those comments have been accepted in a form that should satisfy those supporting the concept. Projections into the required width of the corridor would be permitted for wheeled equipment, provided the equipment does not reduce the clear, unobstructed corridor width to less than 5 feet (1.5 meters); the health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency; and the wheeled equipment is limited to equipment and carts in use, medical emergency equipment not in use, and patient lift and transport equipment.
Supporters of the provision feel that this is a constructive change, as it addresses several problems plaguing hospitals while ensuring that a 5-foot (1.5-meter) clear corridor is maintained. Others believe that this is tantamount to opening Pandora’s box, that permitting more items in the corridor could introduce potential hazards and be difficult to enforce. Additional changes to corridors address projections from the wall such as artwork, bulletin boards, and display cases.
A trio of proposed changes is being driven by the "culture change" movement taking place in the residential care industry, which provides a more residential, home-like feel for occupants. A fixed furniture change states that where the corridor width is at least 8 feet (2.4 meters), projections into the required width can be permitted for fixed furniture, provided that the furniture is securely attached to the floor or a wall, that it does not reduce the clear unobstructed corridor width to less than 6 feet (1.8 meters), except as permitted, and that it meet a number of other requirements. Another change would allow for occupant-use kitchens that open to corridors or common spaces. Part of the culture-change philosophy is that open kitchens in residential care facilities allow for more socialization. However, the potential hazard associated with an open kitchen and how it interacts with the means of egress was addressed by requiring additional smoke detection and use of cook tops with built-in fire protection systems and minimum ventilation exhaust rates. A final proposal would allow some decorations in occupant rooms and common areas. Although this group of culture-change-related proposals was rejected during the proposal period, a task group worked to put together a series of comments that have been accepted the committee.
A staple in the code for almost 20 years, the requirement that smoke barriers be installed on the story below a health care occupancy in new construction has come under question in several proposals and comments. Opponents do not see any benefit to the barrier, as it is not required to be aligned with barriers on the health care story above. Supporters of the requirement object to potentially having a wide open story immediately below an operating room, intensive care unit, or similar location.
While the committee rejected this at both the proposal and comment stage, it is anticipated that this issue may become the subject of a NITMAM. The committee did add an exception for such stories when they only house mechanical equipment.
The code has made great steps over the last 12 years to continue to improve the life safety of occupants of health care facilities, while at the same time trying to maintain or reduce costs for those facilities. The code is also moving forward, and will continue to move forward, on the culture-change initiative. Those in fire protection and those in health care will continue to work to provide cost-effective life safety from fire while recognizing the needs of the patients, residents, and staff of these facilities.
James K. Lathrop is vice-president of Koffel Associates, Inc., a fire protection and life safety engineering, design, and consulting firm in Elkridge, Maryland. He chairs the NFPA 101 Technical Committee on Means of Egress and serves as a member of the Fire Prevention Code Technical Committee and the NFPA 99 Fundamentals Committee. Jennifer Frecker is a health care specialist and fire protection engineer for Koffel Associates and is an alternate on three NFPA committees, including the Health Care Emergency Management Security Committee for NFPA 99.
SIDEBAR
Risk, Wet Locations + More
Also on tap for Boston: A revised version of NFPA 99
As with NFPA 101®, Life Safety Code®, the edition of NFPA 99, Health Care Facilities, currently used by key health care funding and regulatory bodies is older and does not reflect the most up-to-date approaches to safety in those occupancies. The new and significantly revamped version of NFPA 99, which will be considered by NFPA members in Boston in June, is more performance-oriented and reflects newer technologies, and its broad base of supporters say that its adoption by the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) — both of which reference the 1999 edition of NFPA 99—will benefit not just patients but the health care industry as a whole.The standard has not been updated since 2005.
While NFPA 99 is a very useful standard, it has also been challenging to use and apply, mostly because it was originally a compilation of 12 NFPA documents that each addressed different issues in health care facilities. Over the years, these separate considerations have been shaped into a more cohesive document. At the same time, there was a desire to make the document more performance-oriented. After the 2005 edition was issued, the Technical Correlating Committee (TCC) chair felt there was a need to take a fresh look at NFPA 99 and asked the Standards Council to approve extending the code’s cycle from the normal three years to five. Under the direction of TCC Chair Doug Erickson of the American Society for Healthcare Engineering, numerous task groups were organized to completely rewrite NFPA 99. The plan called for the new 2010 edition of the standard to be considered at the 2009 NFPA Conference & Expo.
The process proved difficult, due in part to the scope of the project and the range of subjects addressed in the document. Issues arose, some procedural and some technical, including the decades-old controversy over determining so-called "wet locations" in hospitals, which would require the installation of isolated power supplies. (The wet locations issue became the subject of a recently released Fire Protection Research Foundation study, available online at nfpa.org/foundation.)
Another point of contention focused on the differences among NFPA 99, NFPA 101, and NFPA 13, Installation of Sprinkler Systems, and stemmed from a proposal in NFPA 99 to exempt some locations, such as closets, from sprinkler protection.
These issues and others prompted members to vote to return NFPA 99 to committee for further work. Since the next edition of NFPA 101 was scheduled for the 2011 Conference & Expo, it was determined that the process for NFPA 99 should go back to the Report on Proposals stage, which would also put NFPA 99 on track for the 2011 meeting, ensuring that the next edition of NFPA 101 would have the new edition of NFPA 99 as a referenced document.
A large technical change to the standard proposes that the existing occupancy chapters be deleted and that "risk categories" for different health care occupancies be established in their place. A facility’s requirements would be based on a risk assessment of the procedures actually taking place in the facility, rather than on the term applied to the occupancy, such as "hospital," "nursing home," "outpatient clinic," and so on. The change is being made to better reflect the type of procedures being done — and the risks they entail — in a range of occupancies. Rapid advances in medical technology mean that a procedure that up until recently was only performed in a hospital can now be done in an outpatient clinic. Focusing on risk, advocates argue, places the emphasis correctly on the procedure rather than the occupancy. The issue of risk categories continues to be a major part of the rewrite of NFPA 99.
Other proposed changes include the deletion of the chapter on laboratories, with the idea that the material is covered by NFPA 45, Fire Protection for Laboratories. It has also been proposed that the term "wet locations" be changed to "wet procedure locations" and that "operating rooms shall be considered a wet procedure location unless a risk assessment conducted by the health care governing body determines otherwise."
This provision provided lively discussion at the 2009 Conference & Expo. At the upcoming conference, the selective coordination of overcurrent protective devices in those areas will most likely generate discussion.
SIDEBAR
101, delivered
A new NFPA program offers onsite Life Safety Code prep for TJC audit
According to The Joint Commission (TJC), Life Safety Code® violations are among the most-cited violations in the audit process — but NFPA’s Life Safety Code experts can help.
NFPA’s new "Life Safety Code Audit Preparation Seminar for Health Care Facilities" is designed to do exactly what it says: prepare health care facility managers and staff for the TJC audit process. The two-day seminar is led by an NFPA code expert at your facility and includes a review of your facility’s floor plans and schematics so that the training relates to the specific conditions in your facility. Customized, site-specific content helps your staff gain a greater understanding of the full impact Life Safety Code issues can have on their jobs, and they will know how to identify and deal with compliance issues more effectively in the future.
For more information, click on "training" at nfpa.org. To schedule an onsite NFPA seminar, call 1-877-336-3280 or email onsiteseminars4@nfpa.org.