Transcript No Slide Title

Biggest Pitfalls and Best Practices: Life Safety
What Should I Know About
the Life Safety Chapter?
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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
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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
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Life Safety Compartmentation
1-hour Fire Barrier 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
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Life Safety Compartmentation
2-hour Fire Barrier 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)
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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)
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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”
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Interim Life Safety Measures
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
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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”
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Interim Life Safety Measures
Example Interim Life Safety Measures Policy
Purpose
Interim life safety measures
evaluation exception for
“routine work orders or
superficial projects that do
not impact life safety”
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.
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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
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Interim Life Safety Measures
Appendix A - Interim Life Safety Applicability Form
Description of Project or Deficiency: _________________________________________
________________________________________________________________________
Location: ________________________________________________________________
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
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
_____________________________
Signed
______ ILSM measures do apply
_________________________
Title
Healthcare Engineering Consultants
______________
Date
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.
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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
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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 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
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Interim Life Safety Measures (ILSM)
X
X
X
X
Breach
compartmentation
X
X
X
X
X
Hot work
Large quantities of
combustibles
X
X
X
X
X
X
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X
X
X
X
X
X
X
X
X
X
Fire watch
X
X
Other
X
X
Surveillance
Fire drills
X
X
Staff training
Prohibit smoking
X
Compromise egress
Impair fire detection,
alarm, suppression
Reduce combust.
X
Fire equipment
Barriers
Deficiency
Operational LS
Measure
Notify Fire Dept
Interim
Ensuring Egress
Applicability Grid Example for Interim Life Safety Measures
Interim Life Safety Measures
Example for Interim Life Safety Measures Chart
Appendix B - Interim Life Safety Measures Chart
Description of Project or Deficiency: _________________________________________
________________________________________________________________________
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
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)
Increased surveillance of buildings, grounds or equipment
Y
N
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
Additional staff training for impaired fire safety features
Y
N
Y
N
Additional comments related to required measures: ____________________________
______________________________________________________________________
_____________________________
Signed
_________________________
Title
Healthcare Engineering Consultants
______________
Date
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!
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Interim Life Safety Measures
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Interim Life Safety Measures
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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”?
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Fire Watch “Decision Grid”
Appendix C – Fire Watch Decision Grid
Description of Project or Deficiency: _________________________________________
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”
________________________________________________________________________
Location of Project or Deficiency: ____________________________________________
Fire Watch Notification:
______ Fire Department
______ Insurance Company
______ Other Responders
______ 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
Fire Watch Required?
Service” Condition
Multiple fire alarm or sprinkler system components out-ofNo
service for less than 4 hours in a 24-hour period
Fewer than 6 smoke detectors in the same area out-ofNo
service for more than 4 hours in a 24-hour period
Extinguishing system in less than a single smoke compartNo
ment out-of-service for more than 4 hours in a 24-hour period
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
Extinguishing system in more than a single smoke compartment out-of-service for more than 4 hours in a 24-hour period
Any combination of fire detection and extinguishing devices
out of service > 4 hours in a 24-hour period at the same time
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
_____________________________
Signed
Yes
Yes
Yes
Y
N
Y
N
_________________________
Title
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______________
Date
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
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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?
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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
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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
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Interim Utility System Measures
Interim Utility System Measures
Describe what actions the
project requires
Project Number: _________________
Affected System: Fire System: _____
Date: ____________________
Emergency Power _____
Medical Gas: _____
Description of Project: ______________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Be sure to notify the staff
and departments that will be
affected, and which special
procedures are necessary
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: ______________________________________________________
_________________________________________________________________________
Maintain this and other
related documentation in
the project file
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Date Project Completed: ___________________ Reviewed By: ____________________
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Life Safety Pitfalls
Other Life Safety
Deficiencies that are
Likely to be Found
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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
Patient Areas in Existing Facilities
6 feet
Non-Patient Areas (new and
existing)
48 inches
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
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Compartmentation Deficiencies
What’s wrong
with this seal?
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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
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Egress Corridor Deficiencies
What’s wrong
with this
picture?
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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)
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Egress Corridor Storage
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!!
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Egress Corridor Storage
Joint Commission Corridor Interpretations
Staff Office
Permitted
Storage Space
(if <50 sq ft)
8’ Width Egress Corridor
Exit
Stair
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Egress Corridor Storage
Joint Commission Corridor Interpretations
Staff Office
44”
Permitted
Storage Space
(if <50 sq ft)
8’ Width Egress Corridor
Exit
Stair
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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
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FSES – Occupancy Risk Factors
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FSES – Safety Parameter Values
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FSES – Individual Safety Evaluations
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FSES – Fire Zone Equivalency Evaluation
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FSES – Fire Zone Equivalency Evaluation
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Biggest Pitfalls and Best Practices: Life Safety
Questions?
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