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Volume 6 / Issue 4
                            News                                                                                     July / August 2008

                               Eliminating Immediate Threat to Life
                               Situation Time Limit
                               By Dean Samet, CHSP -

                               At a March 2008 Joint Commission (TJC) Accreditation Committee meeting, it was decided, effective
                               immediately, a time limit will be set to eliminate an “immediate threat to life” situation for all TJC
                               accreditation programs. An organization has up to 72 hours to completely eliminate an immediate
                               threat. (See Joint Commission Perspectives®, May 2008, Volume 28, Issue 5.)

                               It is always expected that organizations will take immediate action when discovering, encountering, or
  “. . . it behooves           facing any immediate threat to life situations. However, in some cases, TJC is allowing organizations
                               up to 23 days maximum to resolve issues if the immediate threat cannot be corrected within 72 hours.
  organizations to
  respond as quickly           If after discovery by a surveyor followed directly by an expedient internal TJC review process, TJC
                               believes an immediate threat to life exists, their president or a designee will issue an expedited Prelimi-
  and effectively as           nary Denial of Accreditation (PDA) decision. The organization will be notified and the PDA decision
                               will be posted on The Joint Commission’s Quality Check® Web site, and appropriate governmental
  they can . . . ”             agencies will be notified at that time. The organization is given five days to notify TJC if it wishes to
                               appeal the PDA decision.

                               After notification of the PDA decision, an organization has up to 72 hours to do the following:

                               •   Eliminate the immediate threat to life situation entirely (example: removing adult medication
                                   doses from a pediatric unit); or

                               •   If the situation is such that it will take the organization additional time to fully eliminate (example:
                                   something involving building construction), then they must implement interim life safety measures
                                   (ILSM) to abate the risk to patients (example: cease performing a certain procedure and implement
                                   additional life safety measures) within 72 hours. If the situation is not fully eliminated or resolved
                                   within 72 hours, the organization will have, at a maximum, up to 23 days to do so.

                               •   Note: In a footnote in the above referenced Joint Commission Perspectives® article, TJC states
                                   that “interim life safety measures” now refer to any safety measure(s) implemented to preserve
                                   life, whether related to the traditional Life Safety Code® deficiencies, renovation or construction
   IN THIS ISSUE:                  activities, or some other immediate threat to life situation. (See Standard EC.5.50 in HAS manual
                                   for previously defined ILSMs.)
  Threat to Life
                               Once The Joint Commission has been notified by the organization that it has abated the immediate
  Smoke Barriers               threat to life situation, TJC will conduct an “abatement” survey to validate the abatement. If the
                               abatement survey confirms the absence of the immediate threat to life situation, TJC will remove the
  Infection Control Measures
                               PDA decision. Therefore, it behooves organizations to respond as quickly and effectively as they can to
  Publications / Seminars      remove or resolve the immediate threat to life situation.
 Smoke Barriers/Partitions/Walls/Compartments
 What’s the Difference?
 By Mike Hawkins -

 Throughout the country health care organizations confuse terminology relative to smoke barriers, smoke compartments, and smoke
 partitions. From time to time we also hear other terms such as smoke walls, smoke-tight and smokeproof. Before we consider some of
 their applications relative to health care occupancies, it is important to understand these terms as defined in Chapter 3 of the 2000 edition
 of NFPA 101®, Life Safety Code®:

                                      Smoke Barrier: “A continuous membrane, or a membrane with discontinuities created by protected
                                      openings, where such membrane is designed and constructed to restrict the movement of smoke.”

                                      Smoke Compartment: “A space within a building enclosed by smoke barriers on all sides, including
                                      the top and bottom.”

                                      Smoke Partition: “A continuous membrane that is designed to form a barrier to limit the transfer of

 While The Joint Commission’s Statement of Conditions™ does not use the term “smoke-tight,” the Life Safety Code® applies the term to
 joints made within or between fire barriers; the top of the smoke partition and the bottom of the suspended ceiling; and in existing health
 care occupancies for corridor partitions that terminate at monolithic ceilings that resist the passage of smoke where there is a smoke-tight
 joint between the top of the partition and the bottom of the ceiling.

 Likewise, the Statement of Conditions™ does not use the term “smokeproof” except as related to a smokeproof enclosure as noted in
 PART 2 - Basic Building Information. The Life Safety Code® defines the term “smokeproof enclosure” as, “A stair enclosure designed to
 limit the movement of products of combustion produced by a fire.”

 The NFPA 101® Life Safety Code® 2000 edition recognizes different types of smoke resisting assemblies:

 Smoke Barrier
 When referring to the Existing Health Care Occupancy, Chapter 19, the Code states in that, “Any required smoke barrier shall be
 constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than ½ hour.” Smoke barriers are required to
 be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or a combination
 thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling. Smoke barriers generally
 establish the limits of smoke compartments by subdividing building spaces. Smoke barriers can be used in conjunction with fire barriers
 if the fire barrier meets the same requirements as the smoke barrier.

 Smoke Partition
 Covered in 8.2.4, smoke partition requirements are typically applied to corridor walls or ceilings in different occupancies but not to
 smoke barriers, although there are many similar requirements for both. When smoke partitions are required by the Code, self-closing
 devices are required for doors per 7.2.1 and no louvers are permitted. Annex A 3.3.185 states, “A smoke partition is not required to have
 a fire resistance rating.” However, the health care occupancy chapters have their own requirements for construction of corridor walls (see & Section of the Code states that “Corridor walls shall be continuous from the floor or roof deck above,
 through any concealed spaces, such as those above suspended ceilings… and they shall have a fire resistive rating of not less than ½
 hour.” There is an exception to this provision. In smoke compartments protected throughout by an approved, supervised automatic
 sprinkler system in accordance with, a corridor shall be permitted to be separated from all other areas by non-fire rated partitions
 and shall be permitted to terminate at the ceiling where the ceiling is constructed to ‘limit the transfer of smoke.’ Per the Annex, an
 architectural, exposed, suspended-grid acoustical tile ceiling with penetrating items such as sprinkler piping and sprinklers (either
 recessed or pendant type with escutcheons), ducted HVAC supply and return-air diffusers, speakers, and recessed lighting fixtures is
 capable of ‘limiting the transfer of smoke.’ (Continued on page 3)

             Smoke Barriers/Partitions/Walls/Compartments
             What’s the Difference? (Continued from Page 2)
             Smoke Compartment
             According to, in Existing Health Care Occupancies, “Smoke barriers shall be provided to
             divide every story used for sleeping rooms for more than 30 patients into not less than two smoke
             compartments. The size of any such smoke compartment shall not exceed 22,500 sq. ft., and the travel
             distance from any point to reach a door in the required smoke barrier shall not exceed 200 feet.”
             New Health Care Occupancies,, requires that buildings containing health care facilities shall
             be subdivided by smoke barriers as follows:
             1. To divide every story used by inpatients for sleeping or treatment into not less than two smoke
             2. To divide every story having an occupant load of 50 or more persons, regardless of use, into not
                  less than two smoke compartments.
             3. To limit the size of each smoke compartment required by (1.) and (2.) to an area not exceeding
                  22,500 sq. ft.

             In summary, while similar language is used to define both smoke barriers and smoke partitions, and
             both perform similar functions, smoke barriers are specifically required in certain Life Safety Code®
             chapters to subdivide building spaces into smoke compartments for the purpose of restricting the
             movement of smoke. They are typically required to be rated at either 30 minutes or one hour. Smoke
             partitions, however, are generally equated with corridor walls or ceilings that are not required to have
             a fire-resistive rating, such as those in a fully sprinklered smoke compartment or building but are still
             required to limit the transfer of smoke.

             Through an understanding of the above Life Safety Code® definitions and requirements, we can help
             ensure that required smoke barriers and smoke partitions are constructed properly and smoke com-
             partments are located on floors where required.

             Accountability in Infection Control
             By Barbie Pankoski, CHFM, CHSP -

             We have all experienced the push in recent years to enforce infection control measures while perform-
             ing maintenance and construction in a health care environment, but have we trained the personnel on
             how to implement these procedures? All too often the facility managers, safety officers, and Environ-
             ment of Care managers are trained on the information but fail to deliver the needed education to the
             staff and contractors who are actually performing the work.

             It is necessary that the staff and contractors understand the importance of protecting patients from
             hospital acquired illnesses and also how they can accomplish this goal. Maintenance staff as well as
             contractors should be familiar with the organization’s Infection Control Risk Assessment (ICRA) poli-
             cies and procedures. Not only should these workers be familiar with the ICRA, they should be able to
             implement the process.

             The Joint Commission’s (TJC) standard EC.8.30 states that, “The organization manages the design
             and building of the environment when it is renovated, altered or newly created.” In order to manage
             this activity, you will need to have trained those that are actually performing the work.

             Lawsuits have held more than just the hospital accountable for hospital acquired illnesses.
                                                                                            (continued on page 4)

                        Accountability in Infection Control Measures                                (continued from page 3)
                        Hospital Facility Magazine reported that a patient acquired an infection due to an airborne fungus that had
                        contaminated the surgical site. The patient sued not only the hospital but named the infection control com-
                        mittee chairman, the infection control practitioner, the general contractor, the sheet metal contractor that
                        had installed an air-handling system, and the environmental testing company that had evaluated the OR
                        after the installation.

                        There are several infection control resources available for guidance during hospital construction and
                        maintenance activities such as the Centers for Disease Control report, “Guidelines for Environmental In-
                        fection Control in Health-Care Facilities, Recommendations of CDC and the Healthcare Infection Control
                        Practices Advisory Committee (HICPAC).” [
                        htm]; the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC); APIC’s report,
                        “The role of infection control during construction in health care facilities” by Judene Mueller Bartley; and
                        Infection Control Magazine at can also be helpful with new ideas
                        and updates for infection control measures.
To learn more about     As healthcare facility professionals, it is imperative that we protect patients while performing maintenance
commissioning and       and construction activities. As the public takes more control over their own healthcare, they expect ac-
LEED, please see the    countability for their safety. We must communicate the hospital’s ICRA policies and procedures to those
SSRCx news here . . .   who may be performing maintenance and construction work in our facilities. The bottom line is that we
                        are all accountable to ensure that the people working in our hospitals have the knowledge they need to per-
                        form their work and duties in an environment that ensures the safety of all patients from hospital acquired
                                                              PUBLICATIONS & SEMINARS

                          Speaking Engagements/Seminars in 2008
                          September 11  Emergency Power Distribution & Control Conference, Philadelphia, PA, “Rx for
                                         Facility Power System Reliability”
                          September 18  Healthcare Technical Conference, St. Louis, MO, “Emergency Power Challenges in
                                         2009 and Beyond”
                          September 26  Safety Officers Network Area Resources, North Platte, NE, “TJC’s New 2008
                                         Emergency Management Standards” and “2009 Life Safety Chapter, Scoring & EC
                          October 7-10  New England Healthcare Engineers Society Fall Conference, New Haven, CT, “New
                                         TJC Emergency Management Standards”
                          October 16    Kansas City Area Healthcare Engineers Conference, “TJC’s New 2009 Life Safety
                                         Standards Chapter & Scoring”
                          October 20-22 EC Summit, Las Vegas, NV, “TJC’s New Life Safety Chapter and Standards
                                        Criticality Scoring Process for 2009” and “Planning for Power Failures”
                          October 27-29 AHCA Conference/Florida Healthcare Engineers Association Annual Meeting, Or-
                                         lando, FL, “Emergency Power Challenges in 2009 and Beyond”
                          October 29-30 South Carolina Society for Healthcare Engineering, Columbia, SC, “NFPA 99” and
                                         “NFPA 110/111”
                          November 5-7  Midwest Healthcare Engineering Conference, Indianapolis, IN, “TJC’s New 2008
                                         Emergency Management Standards: What’s New? What’s Not?” and “Filling the
For more information
                                         Rx for Reliable Power in 2009 and Beyond”
please contact:           November 20   Colorado Association of Hospital Engineers & Directors, Denver, CO, “TJC Newly
                                         Expanded 2008 Emergency Management Standards”
Dean Samet, CHSP
800-545-6732              Compliance News        A newsletter dedicated to accreditation, regulatory compliance and facility management issues           for healthcare executives and facility managers.

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