Barrier Management- Defending the Safety of Patients, Visitors, & Staff

Barrier Management- Defending the Safety of Patients, Visitors, & Staff

About Your Speaker Rick Tinsley: 3 Years as Healthcare Construction Electrician 38 Years in Healthcare Facility Maintenance 13 Years as a Director of Facility Management/Safety/Security 7 Years combined service as President, Secretary/Treasurer, and Education Chairman for the Tennessee Healthcare Engineering Association Lifetime THEA Board Consultant Member of numerous Engineering Societies and Associations AHA Certified Healthcare Facility Manager (CHFM) IBFCSM Certified Healthcare Emergency Professional (CHEP) WIFE Certified Crazy Train Engineer (CCTE)

What is Barrier Management? Barrier Management is ongoing testing and inspections to ensure fire and smoke barriers are functioning properly and meeting designed ratings to protect occupants and infrastructure during a fire. Components of conducting Barrier Management include the following: Physical testing of fire/smoke dampers every 6 years in Hospitals and every 4 years in facilities not classified as a hospital using CMS Conditions of Participation occupancy classifications At least annual inspections of fire doors in rated walls At least annual inspections of rated walls Codes requiring Barrier Management include the following: Dampers NFPA 101, NFPA 80, & NFPA 105 Doors NFPA 101, NFPA 80, & NFPA 105 Walls NFPA 101 & IFC

Components of a Barrier There are many components that create a fire, smoke, or combination barrier. The construction material type: Sheetrock, Concrete, Cinder Blocks, Wood, Steel, etc. Type of material to fill cracks, holes, piping/cable penetrations, fireproofing steel, etc. Fire, smoke, or combination dampers Fire, smoke, or combination doors

Why is Barrier Management Important? Proper Barrier Management along with suppression and alarm systems help protect occupants and structures during the event of a fire. Below are a few examples of how this works: Properly constructed and maintained barriers help contain fire and smoke to a specific area (Compartmentation) Compartmentation gives more time to extinguish the fire and evacuate if needed Compartmentation helps to limit structural and/or contents damage and saves lives Isolating the fire helps to lessen the risk of firefighters getting hurt or killed

Why do I need Smoke Barriers, I have Fire Barriers? Almost 70% of all building deaths are associated with Smoke Inhalation. (Source NFPA) Most victims are not located in the same room as the fire s origin. (Source NFPA) Smoke Travels 120 420 feet per minute under fire conditions. (Source NFPA) Fire creates positive pressure due to the expansion of air from the heat forcing smoke through the smallest hole like air from a compressor. Improper smoke barrier construction/maintenance can result in smoke filling an otherwise survivable space into a deadly area in just minutes.

Why Defend in Place? Healthcare Hospitals, Nursing Homes, Assisted Living Facilities Patients tied to life saving machines or in surgery can t be easily evacuated. Many patients are too sick or non-ambulatory and can t be moved quickly. Multi-story buildings create transportation issues between floors for these patients when elevators can t be used.

Code References Facilities are constructed and maintained using many different codes. Many AHJ s use different editions and/or writers of the codes to inspect your facility. Examples: The State may use a different edition of NFPA 101 for CMS Surveys than they use for a State Survey even though it s the same person doing the survey or the local Fire Marshall may inspect using the IFC, IBC, and IMC codes. So, how do you win? Find out what codes the AHJ s that inspect your facility use and maintain the facility to the most strict code when there is a discrepancy. CMS funded facilities are surveyed by the 2012 Edition of NFPA 101 Life Safety Code, 2012 Edition of NFPA 99 Healthcare Facilities Code, and other associated NFPA codes that are referenced. Architects normally design buildings using the latest State adopted NFPA, IBC, and IMC codes.

Fire & Smoke Dampers

Code Required Testing of Dampers NFPA requirements for damper testing and inspecting are : Each damper shall be tested and inspected 1 year after installation. (NFPA: 105, 6.5.2, NFPA 80: 19.4.1 ) Each damper shall be tested and inspected every 4 years thereafter, except in hospitals where the frequency shall be every 6 years. (NFPA 105: 6.5.2.1, 6.5.2.2., NFPA 80: 19.4.1.1)

Fusible link melts when temperature exceeds the designed rating. Gravity damper Fire shutter Dampers: drops down, closing How the opening. do they Spring loaded damper closes when tension is released. Fire dampers work? do not seal against smoke migration unless rated as a Combination Fire & Smoke Damper. Typical Fusible Link Curtain Fire Damper Multi-Blade Fire Damper

Smoke Dampers: How do they work? Dampers are controlled by an external force either by pneumatic or electrical voltage and activated by an alarm system. The dampers will either open or close according to the type of the designed system using actuator motors. Usually dampers are designed to close and seal the opening from smoke migration. Smoke evacuation systems may either keep the damper open and/or open normally closed dampers to evacuate the smoke from the building.

Smoke Dampers Fail Position: Fail Open vs. Fail Closed Determined by System Actuator Location: External Internal Internal Actuator External Actuator Defective actuators are the #1 source of damper deficiencies.

Combination Fire/Smoke Dampers Perform the dual role of both Fire Dampers and Smoke Dampers Used in locations that are designated as both fire barriers and smoke barriers to prevent the passage of flame and smoke They are activated by heat and/or an alarm system

Smoke Control System Dampers Chapter 9 of the IBC regulates engineered smoke control systems 2 types of Smoke Control Systems: Dedicated and Non-Dedicated Dedicated systems are only activated during an alarm Non-dedicated systems can be used for daily air handling but may function differently as programmed during an alarm

Smoke Control Damper Testing Each damper shall be tested and inspected 1 year after installation. After initial commissioning and testing, dedicated smoke control systems must be tested semi-annually. Non-dedicated systems must be tested annually. Chapter 9 dampers do not fall under the 4 & 6 year rule.

Difference of Passive & Active Smoke Control Systems Passive systems when activated are designed to seal the duct going through a smoke barrier to keep the smoke contained to that area. Active systems use engineered designs to open or close dampers when activated to either evacuate the smoke or to keep smoke out of other areas by adjusting pressures.

What s Wrong With This Picture?

Fire & Smoke Doors

Fire Door Doing Its Job: Non-Fire Side Photo courtesy of NFPA

Fire Door Doing Its Job: Fire Side Photo courtesy of NFPA

2012 LSC 101 Fire & Smoke Door Inspection Requirements 7.2.1.15 Inspection of Door Openings. 7.2.1.15.1 Where required by Chapters 11 through 43, the following door assemblies shall be inspected and tested not less than annually in accordance with 7.2.1.15.2 through 7.2.1.15.8. (1) Door leaves equipped with panic hardware or fire exit hardware in accordance with 7.2.1.7 (2) Door assemblies in exit enclosures (3) Electrically controlled egress doors (4) Door assemblies with special locking arrangements subject to 7.2.1.6 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.

2012 LSC 101 Fire & Smoke Door Inspection Requirements 7.2.1.15.3 The inspection and testing interval for fire-rated and nonrated door assemblies shall be permitted to exceed 12 months under a written performance-based program in accordance with 5.2.2 of NFPA 80, Standard for Fire Doors and Other Opening Protectives. 7.2.1.15.4 A written record of the inspections and testing shall be signed and kept for inspection by the authority having jurisdiction. 7.2.1.15.5 Functional testing of door assemblies shall be performed by individuals who can demonstrate knowledge and understanding of the operating components of the type of door being subjected to testing. 7.2.1.15.8 Door openings not in proper operating condition shall be repaired or replaced without delay.

Top Fire and Smoke Door Deficiencies Improper clearances between door, frame, and floor Missing or illegible labels on doors & frames Missing, incorrect type, and/or malfunctioning hardware Incorrect type, size, broken, or improper installation of vision panels Damaged door and/or frame (Holes, Warped/Dented, Delamination) Field modifications of door and/or frames Improper size or items attached to doors (Kick Plates, Decorations, Signage, Wall Pockets) Doors propped open (Wedges, Kick Down Holders, Items Placed in Front of Doors) Doors not latching or closing properly (Strikes, Latches, Closers, Coordinators, Tape over latch bolt or strike plate) Doors dragging, rubbing, or binding on floors, each other, and/or frame Improper latching devices (Deadbolts, Hooks, Slide Bolts, Non Rated-Panic Hardware that do not meet fire exit specifications) Electronic latching/releasing devices not working properly

So What Do I Do With The Extra Parts That Come With The New Door Closer?

What Do You Mean By Improper Field Modification?

What Are The 5 Issues With This Fire Rated Door?

What Are The 4 Issues With This Fire Rated Door?

MANAGING FIRE & SMOKE BARRIERS IN TODAY S HEALTHCARE ENVIRONMENT

In the world above the ceiling tiles Out of sight can be out of mind!

Healthcare Specific Issues Key Firestop Compliance Issues: A large % of findings are firestop related. Of those the overwhelming % are cable penetrations Penetrations allow smoke to migrate to other areas Infection Control, specifically related to unsealed penetrations can be a significant issue in critical areas such as isolation rooms, ICU, NICU, etc. Fire Barrier Management over time is a significant challenge for HC facilities if not constantly monitored

Even when we have made the effort Openings that once were sealed may no longer be

I think it looks pretty!

What else can I find to put in here?

I just need to get to the other side!

What Sign?

The System Must Meet The Application Rating Of The Barrier Proper Barrier Construction Proper Sealant Type Annular Space Requirements Meet Approved Testing Lab Installation Requirements More Than Just Red Caulk!!!

What is a Barrier Management Program??? Proactive Approach to Maintaining Rated Wall Integrity. Documentation!!!! Provide Paths for Future Cable Pulls. (Listed Cable Management Systems) Enforce Accountability! Meet or Exceed Inspection/Accreditation Requirements.

Why Do I Need A Barrier Management Program? Regulatory Compliance Insure Proper Installation Exhibit a Proactive Approach Prevent Property Loss Life Safety

A BMP At A Minimum Should Accomplish Four Things: 1. Ensure the delivery of a compliant building 2. Adopt procedures to keep it in compliance 3. Inspections/Testing by code requirements 4. Documentation (Evidence of Compliance)

Barrier Management Program Above Ceiling Permit Form This permit will be given with a designated start and finish date which will be determined by the facility. The permit will allow access above the ceiling. This permit will be displayed at all times.

Firestop Installer Training Should be a requirement for anyone working in barriers Detailed training on the proper installation of firestop manufacturers approved systems & products Testing program requiring annual review Infection Control Training Patient Privacy (HIPAA) Training BMP Protocol Training

Proper Products For Application Insuring the products selected for the applications are correct for the type of penetration, type of object to be sealed around, size of the repair, and testing lab approved installation. What s good for the contractor may not be what s good for the facility. Specialized products for specific testing lab applications are available from firestop manufacturers.

Through-Penetrations

Most Firestop Manufactures Have A Cable Management Solution Products like these provide a long term solution to cable issues by allowing multiple runs to be pulled at different times without making new holes.

Construction Joints Movement Is The Issue: Elastomeric Firestop Required To Ensure Caulk Flexes With The Building Movement

USING YOUR BARRIERS FOR EMERGENCY PREPAREDNESS

How Does Barrier Management & Emergency Preparedness Work Together? Properly maintained barriers can be used for other purposes than to slow the migration of fire and smoke. Smoke dampers can be closed to prevent airflow from a contaminated area to other parts of the facility. Properly sealed walls and floors will prevent airborne viruses and chemical vapors from spreading. Properly latching doors when closed will help protect occupants during violent weather. Properly latching doors when closed will also slow down someone intending to commit violent acts by limiting their line of site and physically having to stop and open doors.

How Can I Make Barrier Management & Emergency Preparedness Work Together? Perform an HVA to determine what your internal vulnerabilities are and what can be done to mitigate. Write Policies & Procedures to Maintain Barriers. Write Policies & Procedures to detail how to implement steps for handling the event. Include HVA and P&P s in your Emergency Operations Plans. Smoke dampers can be set up to manually close with the fire alarm system in zones or stand-alone switching for individual control on passive systems. Cannot be used with smoke evacuation systems. Doors can be manually closed or set up through the fire alarm system to close from a remote location when violent weather is approaching or during an intruder event.

Summary & Conclusion: Initiate a Barrier Management Program including an Above Ceiling Work Permit and give a copy to each contractor. Follow up on contractors to make sure they are properly sealing penetrations before they are paid. Ensure inspections and tests are conducted by qualified individuals/companies and performed on schedule. Repair issues ASAP and perform ILSM s and PFI s if needed. Perform an HVA on Internal Risks Including Fire, Storms, Intruders, and Chemical Spills/Release. Include Internal HVA and BMP in EOC and Emergency Operations Plans. Notify AHJ s that you have a BMP during inspection. Remember that you are responsible for the safety of the occupants and infrastructure of your facility.

Have You Ever Had One Of Those Days?

Questions? Thank you for your time. Contact Info: Rick Tinsley CHFM, CHEP Life Safety Consultant LSS Life Safety Services 615-975-8473 rtinsley@lifesafetyservices.com www.lifesafetyservices.com