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Cover Story

Health Care 101
NFPA 101 provides effective design requirements for improved health care environments.

NFPA Journal®, January/February 2006

by Daniel O'Connor, P.E., and Thomas W. Gardner, P.E.

• Suites
• The need
• Problems with implementation
• The solution
• Other corridor projections
• Retro-fit sprinkler protection
• Lock-ups

The NFPA 101®, Life Safety Code®, and NFPA 5000®, Building Construction and Safety Code ®, Technical Committee on Health Care Occupancies has completed the most recent cycle of work culminating in the requirements now found in the 2006 editions of these codes. Essentially the proposals considered during the code change process on NFPA 101 were identical to those for NFPA 5000, except for requirements related to existing health care occupancies, which are addressed only in NFPA 101.

With health care costs continually on the rise, there is keen awareness among members of the Technical Committee on Health Care Occupancies regarding the costs associated with the built environment of hospitals, nursing homes and ambulatory health care facilities. These considerations for cost however, must be balanced with the overriding concerns for the safety of patients, the public, and the facility staff.

With the release of the 2006 edition of NFPA 101 there have been a number of key areas addressed by the Technical Committee that recognizes that a balance of both safety considerations and cost effective design can result in improved safety in health care environments without undue impact on rising health care costs. This article reviews several key issues addressed by the Technical Committee, which include the design of health care suites, the requirements related to the use of alcohol-based hand rub (ABHR) dispensers for infection control, sprinkler retrofit requirements for existing nursing homes, and several other provisions that provide for design flexibility in health care environments.

Suites
The design of suites has been addressed for many years under the provisions of NFPA 101. These requirements, however, have been dispersed among several topic areas under Chapters 18 and 19 for New and Existing health care occupancies. In the 2006 edition of NFPA 101 the terms “suite,” “non-sleeping suite,” “sleeping suite,” have been defined for the context of health care occupancies. A significant improvement that should alleviate confusion regarding the design of suites is that the various requirements for suites have been reorganized and revised under sections specifically dedicated to the particular type of suites. These NFPA 101 Sections are 18.2.5.6 and 19.2.5.6 for new and existing suites, respectively.

Suites have always been a cost effective solution to addressing the needs of collective groups of patients having similar health issues or needing similar levels of staff monitoring and care. Suite configurations are often used for specialty care patient sleeping units such as intensive care, cardiac care or pediatric care units but may also be effective as treatment suites such as an X-ray suite. In prior editions of NFPA 101, sleeping suites have been limited in area to 5,000 square feet (460 square meters) and required “direct visual supervision by staff,”– a concept that has elicited much discussion and confusion over the years.

Oftentimes facility designers and architects have attempted to push the design limits of sleeping suites beyond 5,000 square feet using equivalency based arguments to interpret in various ways the meaning of “direct visual supervision by staff” as a means of providing a cost effective environment for patients. Cognizant of these reoccurring issues for facilities, the Technical Committee on Health Care Occupancies has increased the area limitation from 5,000 square feet to 7,500 square feet (700 square meters) if the suite has smoke detection and sprinkler protection. In addition, definitive language is provided to address the issue of “direct visual supervision by staff.” The new provisions for sleeping suites of 5,000 square feet or less requires that patient sleeping rooms in the suite be arranged to allow for direct supervision from a normally attended staff location noting specifically that this is accomplished by use of glass walls, i.e. staff can visually see into the patient sleeping room. This, however, does not preclude the use of cubical curtains for use at the patient bed.

A recognized concern of the Technical Committee was that often times there are practical safety concerns of how good visual supervision is for patient sleeping rooms. To address this concern and, again, provide design flexibility any individual patient room that lacks direct visual supervision can be used, but such room will require the installation of smoke detection that will activate the fire alarm system (18.2.5.6.2.1. (C)(1)(b) and 19.2.5.6.2.1. (C)(1)(b)). In the case of sleeping suites that effectively lack a direct visual supervision arrangement, facilities and designers will have the option to provide a total coverage automatic smoke detection system throughout the sleeping suite (18.2.5.6.2.1. (C)(2) and 19.2.5.6.2.1. (C)(2)). This option only applies when the suite is 5,000 square feet or less, whereas, sleeping suites exceeding 5,000 square feet but less than 7,500 square feet are required to provide a total coverage automatic smoke detection system throughout the sleeping suite. It is important to note that while smoke detection offers a solution to substitute for direct visual supervision it is still intended that the suite have staff constantly in attendance.

Flexibility in design while providing adequate safety measures also resulted in several other revisions of the requirements for suites.

• Suites large enough to require two exits – one of the two required means of egress is permitted to be through an adjoining suite provided the wall separating the suites meets the requirements for corridor walls.
• Measurement of Sleeping Suite Travel Distance – When a suite requires two means of egress the 100 feet (30 meters) travel distance requirement to an exit access door from within a sleeping suite may be measured to the corridor door but can also be measured to a second exit access door leading into an adjoining suite. Where the second exit from a sleeping suite is through an adjacent suite, the above 100 feet travel distance limit applies only to the suite under consideration. These clarifications are provided per an annex note in NFPA 101.
• Second exit access through non-sleeping suite – Where the second exit access of a non-sleeping suite is through an adjoining suite, the adjoining suite is not considered an intervening room.
• Fire Retardant Wood in Suites – walls or partitions subdividing areas within a suite can be constructed using fire-retardant-treated wood provided the wood is enclosed by noncombustible or limited-combustible materials, and such partitions are not otherwise required to be fire rated.
• Hazardous areas – Hazardous areas in suites are not required to be separated where all of the following are met:
  - The suite is a hazardous area (e.g., med. records or pharmaceutical)
  - The suite is protected by Smoke Detection (not required in existing occupancies)
  - The suite is separated from the remainder of facility as required for hazardous areas.

The need
In October 2002, the Centers for Disease Control and Prevention  (CDC) issued guidelines that advised the use of alcohol-based hand rubs to protect patients in health care settings. “Clean hands are the single most important factor in preventing the spread of dangerous germs and antibiotic resistance in health care settings,” said Dr. Julie Gerberding, director of the CDC. “More widespread use of these products that improve adherence to recommended hand hygiene practices will promote patient safety and prevent infections”1 Such infections are referred to as “health care acquired infections” or HAIs.

In 2002, CDC made estimates that each year nearly 2 million patients in the United States get a HAI, and approximately 88,000 of these patients die because of their infection. This large number of yearly deaths can be put into perspective when viewed on a daily basis; 250 deaths per day which is equivalent to a commercial airliner crash killing everyone on board each and every day – for a year. As additional perspective, consider that the annual average life loss due to fire in the healthcare environment is fewer than three per year.

Infections are also a complication of care in other settings including nursing homes and clinics. Because health care personnel must constantly move from patient to patient, their schedule makes hand washing with soap and water a difficult chore. The hand rubs help promote hand hygiene because they are much more accessible than sinks, take less time to use and cause less skin irritation and dryness than most soaps. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) weighed in with the CDC when JCAHO’s 2004 National Patient Safety Goals called for hospitals to comply with the CDC guidelines.

Problems with implementation
Facilities had problems installing dispensers since national and local fire codes restricted the location and use of flammable liquids, such as the alcohol based hand rubs. In addition, research indicated that health care workers were more likely to use these hand rubs when dispensers were located in the corridor just outside the patient room. When the CDC guidelines were published, some Authorities Having Jurisdiction (AHJ) objected to the installation of hand rub dispensers in the corridors. In addition to the fact that they contained a flammable liquid, AHJs cited the exception to Section 7.3.2 of the 2000 edition of NFPA 101, which allows projections into the required width of egress of not more than 3.5 inches (8.9 centimeters) on each side (at an elevation of 38 inches (96 centimeters) and below). Many dispensers project 4 inches (10.2 centimeters) from the wall where they are mounted and are usually mounted higher than 38 inches (96 centimeters) above the floor.

Health care organizations that tried to comply with the CDC and JCAHO recommendations found that they were spending time and parts of their already tight budgets on removing these dispensers or defending their installation upon objection of the fire protection AHJ. 

The solution
In July 2003, the American Hospital Association  (AHA) and the CDC co-hosted a meeting about alcohol-based hand rubs with representatives from more than 20 organizations involved in fire safety and health care, including the AHA’s American Society for Healthcare Engineering (ASHE) and NFPA. At this meeting, ASHE provided the results of a fire protection engineering study where a computational fluid dynamics model was used to determine how alcohol-based hand rubs could be safely installed and managed in corridors.

Because of the efforts of ASHE and many other organizations, on May 5, 2004 NFPA issued Tentative Interim Amendment (TIA) 00-1 (101) and TIA 03-6 (101) to the to the 2000 and 2003 editions of NFPA 101 respectively. The TIAs modified NFPA 101 to specifically recognize and permit the use of alcohol-based hand rub solutions in patient rooms, corridors, suites of health care facilities. In the Federal Register on March 25, 2005, the Centers for Medicare & Medicaid Services  (CMS) issued an amendment to “Fire Safety Requirements for Certain Health Care Facilities” File code CMS-3145-IFC which in effect adopted TIA 00-1 (101).

Since TIAs do not go through the entire codes and standards-making process of being published in a ROP and ROC for review and comment, they are effective only between editions of the document.

A TIA automatically becomes a proposal of the proponent for the next edition of the document; as such, it then is subject to all of the procedures of the codes and standards making process. This has taken place with the above TIAs and the Technical Committee on Health Care Occupancies has incorporated requirements for alcohol-based hand rub dispensers in the 2006 edition of NFPA 101 in the following sections:

• 18.3.2.6 for New Health Care occupancies;
• 19.3.2.6 for Existing Health Care occupancies;
• 20.3.2.6 for New Ambulatory Health Care occupancies; and
• 21.3.2.6 Existing Ambulatory Health Care occupancies.

Specifically, the dispensers must be protected in accordance with Section 8.7.3 of NFPA 101 (Flammable Liquids and Gases) unless all of the following conditions are met:

1. Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 feet (1.8 meters).
2. The maximum individual dispenser fluid capacity shall be:
   a. 0.32 gallons (1.2 liters) for dispensers in rooms, corridors, and areas open to corridors
   b. 0.53 gallons (2.0 liters) for dispensers in suites of rooms
3. The dispensers shall be separated from each other by a horizontal spacing of not less than 48 inches (121 centimeters).
4. Not more than an aggregate 10 gallons (37.8 liters) of solution shall be in use outside of a storage cabinet in a single smoke compartment.
5. Storage of quantities greater than 5 gallons (18.9 liters) in single smoke compartment shall comply with NFPA 30, Flammable and Combustible Liquids Code.
6. The dispensers shall not be installed over or directly adjacent to an ignition source.
7. Dispensers installed directly over carpeted surfaces shall be permitted only in sprinklered smoke compartments.

The projection of these dispensers into the width of a corridor was addressed by new sections 18.2.3.4(2) and 18.2.3.5 (2) (new health care occupancies), 19.2.3.4(2) (existing health care occupancies), 20.2.3.3 (new ambulatory health care occupancies), and 21.2.3.3 (existing ambulatory health care occupancies), which allows projections not more than 6 inch (15 centimeters) from the corridor wall above handrail height if the corridor has a minimum width of 6 feet (1.8 meters).

Other corridor projections
The Technical Committee on Health Care Occupancies also processed public proposals intended to provide safe but cost effective design concerning corridor projections other than the alcohol-based hand rub dispensers. Today’s health care occupancies have a growing number of wall-mounted devices intended to assist the health care professionals with the extensive amount of patient data that must be managed in real time. Examples of such devices include wall-mounted charting stations and computers. The Technical Committee has recognized that small projections that do not occupy a majority of the corridor wall will not adversely affect egress.

Where a corridor width is a minimum of 6 feet (1,830 millimeters) wide, sections 18.2.3.4(3) and 18.2.3.5 (3) (new health care occupancies) and 19.2.3.4(3) (existing health care occupancies) allow projections on both sides of the corridor where:

1. No projection shall exceed a depth of 6 inches (150 millimeters).
2. No projection shall exceed a length of 36 inches (915 millimeters).
3. No projection shall be positioned less than 40 inches (1,015 millimeters) above floor.
4. No projection shall have less than 48 inches (1,220 millimeters) horizontal separation between adjacent projections.

Retrofit sprinkler protection
The 1991 edition of NFPA 101 was the first edition to require sprinkler protection for all new health care facilities. After two multiple death nursing home fires within seven months of each other in 2003 – Hartford, Connecticut on February 26, 2003 and Nashville, Tennessee on September 25, 2003 – that resulted in a total of 31 deaths, there were calls for requirements to retro-fit sprinkler protection in existing nursing facilities.

In October 2003, NFPA President and CEO James Shannon called for sprinkler protection of all nursing facilities. In 2004, the American Health Care Association (AHCA), which is the trade association for Nursing Homes in the United States, urged Congress to take action on the Nursing Facility Fire Safety Act – legislation that was offered in the previous congressional session. If passed, this fire safety act would, within five years from adoption, ensure that every nursing home in the country is retrofitted with automatic fire sprinkler protection. Later, AHCA made a public proposal to NFPA 101 that would require retrofit sprinkler protection for existing nursing homes, which resulted in Section 19.3.5.1 in the 2006 edition.

Full sprinkler protection obviously increases the level of fire protection and life safety in nursing homes but what about the impact on scarce health care funding? While the design, installation, and maintenance of sprinkler systems in nursing homes will have a measurable cost, which can be affected by the available or lack of an acceptable water supply, there are savings associated with the retrofit of these systems such as:

• Some buildings of non-compliant construction types could “become” compliant, negating the need for equivalencies, other alternate means of protection or waivers.
• Increased allowable travel distances permitted in sprinklered facilities could solve existing egress problems and/or facilitate building additions;
• The requirement for the enclosure of hazardous areas would change from 1-hour fire resistance to smoke partitions. In most cases, the facility would save money because fire stopping of penetrations in the enclosure above the ceiling would no longer be necessary.
• Some waiting areas would be allowed to be open to the corridor.
• Some gift shops would be allowed to be open to the corridor.
• Certain spaces other than patient sleeping rooms, treatment rooms, and hazardous areas could be open to the corridor.
• The requirement for the construction of corridor walls would change from 1/2-hour fire resistive “full height” walls to non-fire rated partitions permitted to terminate at most ceilings. In most cases, the facility would save money because fire stopping of penetrations in the corridor wall above the ceiling would no longer be necessary.
• The restrictions in size and fire resistance of glass/frames would be eliminated.
• The requirement for many of the corridor doors to be of certain construction materials would be eliminated.
• The requirement for doorframes to be labeled and of steel construction would be eliminated.
• The allowable aggregate area of miscellaneous openings (e.g., mail slots, pharmacy pass-through windows, laboratory pass-through windows) per room increases from 20 inches2 (0.015 meters2) to 80 inches2 (0.05 meters2).
• The requirement for smoke dampers in duct penetrations of smoke barriers in fully ducted HVAC systems would be eliminated. Facilities could disconnect existing dampers, fix them in the open position and save money on future testing and maintenance.
• Newly introduced upholstered furniture and mattresses could be of the less expensive type since they would not have to comply with Chapter 10 (Interior Finish, Contents, and Furnishings).

The Nursing Facility Fire Safety Act would:

• Create a funding stream to pay for sprinkler retrofits through Medicaid and Medicare.
• Allow nursing homes to amortize over five years the cost of retrofitting existing facilities.

Lock-ups
A new provision of the 2006 edition of NFPA 101 requires that lock-up facilities in other than detention and correctional occupancies comply with Sections 22.4.5 of the detention and correctional occupancies chapters. Many non-detention and correctional occupancies have lock-up areas. For example “holding” or lock-up areas in a football stadium (assembly occupancy) are places where persons - who were arrested during a game - would be detained until they could be processed by police. Such facilities must now comply with the new requirements for lock ups.

The Technical Committee on Health Care Occupancies specifically excluded health care occupancies from these new requirements because when health care facilities lock someone up, it is because the “clinical needs of the patient” dictate the necessity for such restraint. Chapters 18 and 19 of NFPA 101 contain specific provisions that address locked health care environments.

The 2006 edition of NFPA 101 defines the state-of-the-art in health care fire safety for the built environment of hospitals, nursing homes and ambulatory care facilities. Recent changes that have formed the 2006 edition of the NFPA 101 are based on many years of fire performance/history, data, fire protection engineering, and advocacy by many dedicated professionals to balance cost with the safety of patients, the public, and the facility staff.

Endnotes

1. Guideline for Hand Hygiene in Health-Care Settings, Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, October 25, 2002, Vol. 51, No. RR-16, U.S. Department of Health and Human Services, Atlanta, GA.

Daniel J. O’Connor, P.E. is the Vice President of Engineering for Schirmer Engineering Corporation in Chicago. He is also the chairman of the Technical Committee on Health Care Occupancies.

Thomas W. Gardner, P.E. is the principal in charge of the Atlanta area office of Schirmer Engineering Corporation. He is a member of the Technical Correlating Committee on Health Care Facilities and the editor of the NFPA Health Care Facilities Handbook.