Biggest Pitfalls and Best Practices: Life Safety

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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 gt16 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
• 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

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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 PFIs!
• Include in the ILSM policy exclusions for
  evaluations, such as routine work orders or
  superficial projects

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Interim Life Safety Measures
Interim life safety measures evaluation exception
for routine work orders or superficial projects
that do not impact life safety
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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
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
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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)
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
Ensuring Egress
Barriers
Notify Fire Dept
Fire equipment
Fire drills
Operational LS
Reduce combust.
Fire watch
Prohibit smoking
Other
Staff training
Surveillance
Deficiency
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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

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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
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
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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
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
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Life Safety Pitfalls
Other Life Safety Deficiencies that are Likely
to be Found
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Life Safety Deficiencies
Additional Note Joint Commission now accepts up
to 6 inch projections above 40 inches from the
floor
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Compartmentation Deficiencies
Whats 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
Whats 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 (COWs)
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 COWs 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
• 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 AHJs may not
  permit these exceptions! Be careful!!

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Egress Corridor Storage
Joint Commission Corridor Interpretations
Staff Office
Permitted Storage Space (if lt50 sq ft)
8 Width Egress Corridor
Exit Stair
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Egress Corridor Storage
Joint Commission Corridor Interpretations
Staff Office
Permitted Storage Space (if lt50 sq ft)
44
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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