Assessing Whether Your Wound Clinic is Up to ‘Code’

  Given the growing of patient populations and newly adopted safety codes, your wound clinic may not be considered “safe” today. Has your facility adapted to what is considered “best practices” in safety? In order to help you answer this question, the National Fire Protection Association (NFPA) publishes more than 300 codes and standards on fire and other hazards. These documents are regularly updated — some every three years, some every five years. NFPA code No. 101 Life Safety Code® and NFPA code No. 99 Health Care Facilities Code are two codes that apply to wound clinics. Both codes are updated every three years and contain information to help assess facility safety. If your facility participates in any of the provider programs regulated by the Centers for Medicare & Medicaid Services (CMS) or if you are subject to any of the healthcare accreditation programs that are offered, you should already be familiar with these documents. For those who are not or could use a refresher, this article is intended to assist.

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Regulatory Landscape

  At present, federal regulation and oversight of the healthcare environment through the Conditions of Participation administered by CMS requires compliance with the 1999 edition of NFPA 99 and the 2000 edition of NFPA 101. While a few provisions from the 2012 edition of these codes are allowed under some circumstances, much of the regulation rests with the older editions. On April 16, 2014, CMS issued a Notice of Proposed Rule Making (NPRM) that officially starts the process to move away from the 2000 edition to the 2012 edition of NFPA 101 as well as to adopt the 2012 edition of NFPA 99. The NPRM addresses healthcare and ambulatory healthcare occupancies and sets in motion a period of transition to a set of new requirements that are sure to be championed by a range of constituents. Although the comment period for the rule closed in June 2014, no timeline has been provided with regard to when the rule will be finalized. This change will affect all providers who treat patients who are on Medicare and Medicaid and are reimbursed for the treatment.

Life Safety Code

  Before reviewing some of the updates to the codes, it is important to understand how NFPA 101 applies to wound clinics. Facilities that typically provide services to four or more patients on an outpatient basis are considered ambulatory healthcare (AHC) occupancies by the NFPA. What makes these facilities unique is 1) the occupants (patients) can be incapable of self-preservation and 2) the facility provides less than 24 hours of care. Within NFPA 101, there are two chapters dedicated to AHC facilities. Chapter 20 addresses new facilities and Chapter 21 addresses existing facilities. Because some patients in an AHC facility cannot independently evacuate the building, there is a heavy reliance on staff assistance to “minimize the possibility of a fire emergency requiring the evacuation of occupants.” These provisions are supplemented by specific building features including regulation of allowable building construction types and use of fire alarm and automatic fire sprinkler systems. This article will focus on some of the unique and new requirements found in Chapter 21 (existing AHC), including means of egress, alcohol-based hand-rub (ABHR) dispensers, cooking facilities, interior finish, and separation requirements.

  While some AHC requirements remain the same between the two editions of NFPA 101, a few notable provisions exist. Not less than two exits shall be provided on each floor or fire section of the building and the travel distance to the exit shall not exceed 150 feet (200 feet for sprinklered buildings). The means of egress should be maintained clear from any obstructions and the clear width of corridors or passageways leading to an exit shall not be fewer than 44 inches in width. Evacuation and relocation plan requirements are also important because of the reliance of staff to move occupants to safety. All employees should be routinely instructed and be required to practice fire drills, which are required to be conducted quarterly on each shift, per the code. Drills are not intended to include relocation of patients. Patient relocation and staff response procedures should all be covered in a fire-safety plan that all facilities must develop and make visible at all times.

  In 2006, NFPA 101 introduced new requirements on ABHR dispensers. The 2012 edition of 101 contains 11 requirements to meet in order to use these devices in an AHC facility. For example, the capacity of individual dispensers shall not exceed 0.32 gallons in rooms or corridors and they must be spaced at least 48 inches horizontally from one another. It is important to note that CMS published an allowance to use these requirements in 2005.

  Domestic cooking facilities used for food warming or limited cooking are permitted by the 2012 edition. Such equipment might be present for rehabilitation uses, but the code mandates no special provisions. Each story in an AHC facility is required to be subdivided into no fewer than two smoke compartments (unless one of three expectations is met, contact NFPA for more information). These compartments help to serve as a safe space for patients and staff to retreat to should a fire occur prior to having to exit the building. Testing requirements for newly introduced upholstered furniture and mattresses in sprinklered buildings were reduced and additional options for combustible decorations were added. In addition to the many electrical requirements, including emergency lighting and illumination, there is a requirement for any general anesthesia or life-support equipment to be provided with an essential electrical system in accordance with NFPA 99.

Healthcare Facilities Code

  The NPRM referenced earlier also includes adoption of the 2012 edition of NFPA 99 and, unlike NFPA 101, applies exclusively to healthcare facilities. While the preceding discussion of NFPA 101 talks about ambulatory healthcare occupancies, NFPA 99 applies to health care facilities, which are defined as any buildings, portions of buildings, or mobile enclosures in which medical, dental, psychiatric, nursing, obstetrical, or surgical care is provided. This wide-ranging definition means NFPA 99 can apply to everything from 1,000-bed hospitals to small outpatient clinics located in office buildings. The level to which the code is applied to different facilities is based on the risk to patients, caregivers, and visitors rather than simply what the building is called. While much of the code applies to new construction, there are numerous requirements applicable to existing facilities.

  NFPA 99 addresses a range of topics from piped medical gas and vacuum systems to electrical systems, including emergency power supplies, if needed, electrical and gas equipment, emergency management, and hyperbaric chambers and facilities. Most requirements for an existing facility are minimal and include inspection, testing, and maintenance (ITM) of systems and equipment. In many cases, for smaller facilities that are part of a larger building, the building owner is responsible for much of this, while suppliers of equipment provide services or at least information for the ITM of their products. However, it is up to the healthcare facility itself to ensure these tasks are performed.

Gas Cylinders

  Maintaining compliance with NFPA 99 in daily operations includes the proper storage of gas cylinders, which present hazards in the form of increasing the concentration of oxygen in the air if there is a leak, and thus increasing fire risk. They can also be mechanical hazards, turning into projectiles if their valves are damaged. Rooms containing supply systems for piped gas systems, including those for hyperbaric chamber supplies, must meet relatively stringent requirements of the code including limitations on what can be stored in the same room and maintaining acceptable temperatures. Storage of cylinders containing smaller volumes of gas, as is more typical in outpatient settings, also holds specific criteria. Doors to rooms containing gas cylinder storage must have signage alerting staff to room contents. There must be a separation from the cylinders and combustible or flammable materials of 5 feet where the storage location has fire sprinklers and 20 feet where there are no sprinklers, or they must be stored in an enclosed cabinet. A small number of cylinders are allowed outside of storage, provided that the total volume of gas in these cylinders does not exceed 300 feet.3 Policies must also be established to eliminate potential sources of ignition from any areas where a patient will receive respiratory therapy.

Hyperbaric Facilities

  Hyperbaric chambers and rooms or areas that house them are covered in Chapter 14 of NFPA 99. This includes requirements for both Class A (multiple occupancy) and Class B (single occupancy) chambers. The hazards presented by hyperbaric operations (eg, high pressure, oxygen-enriched atmospheres) are present throughout the life of the system and there are many requirements that must be met to provide appropriate safety. Perhaps the most important provision to ensure ongoing safety and compliance is to appoint a hyperbaric safety director.

  The code states that each hyperbaric facility must appoint an onsite hyperbaric safety director who is in charge of all hyperbaric equipment and the operational safety requirements of Chapter 14. It is suggested that this person not be the same individual who is the medical director for hyperbaric treatment. This recommendation is not intended to create an adversarial relationship or to place the safety director above the medical director in an organizational structure. It is intended to create a collaborative relationship where the medical director can focus on medical issues and the safety director can focus on technical issues.

  The responsibilities of the hyperbaric safety director include:
    • developing minimum staffing levels in conjunction with the hyperbaric medical director;
    • restricting or removing potentially hazardous items from the chamber;
    • ensuring inspection and testing of equipment is part of routing maintenance;
    • developing emergency procedures specific to the hyperbaric facility;
    • training all personnel in emergency procedures; and
    • conducting emergency-procedure and fire-training drills at least annually.

  Specific details on these responsibilities and other requirements are included in NFPA 99. The hyperbaric safety director should have a detailed understanding of not only what the requirements are but why they are in place in order to develop appropriate plans and to communicate the necessity of planning and training to other personnel.

Tracy Vecchiarelli is a fire protection engineer at NFPA. She joined the NFPA staff in 2010 and serves as staff liaison to several technical committees. Jonathan R. Hart is a fire protection engineer for NFPA.

Resources

  For a complete comparison of the changes between the 2000 and 2012 editions of NFPA 101, visit www.nfpa.org/101.