Compliance rates low on egress, fire safety

For the first time in several years, The Joint Commission standards and goals with the lowest compliance rates are not directly related to the delivery of health care. In its annual listing of the standards or goals with the highest rates of noncompliance for the first six months of 2009, The Joint Commission listed the following:

  • Life Safety (LS) 02.01.20: The hospital maintains the integrity of the means of egress, 45% noncompliant;
  • LS.02.01.10: Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat, 43% noncompliant;
  • Record of Care, Treatment, and Services (RC) 02.03.07: Qualified staff receive and record verbal orders, 40% noncompliant;
  • Environment of Care (EC) 02.03.05: The hospital maintains fire safety equipment and fire safety building features, 38% noncompliant;
  • National Patient Safety Goal (NPSG) 02.03.01: The hospital measures, assesses and, if needed, takes action to improve the timeliness of reporting and the timeliness of receipt of critical tests and critical results and values by the responsible licensed caregiver, 38% noncompliant.

With ED managers often playing a key role in disaster planning, and with EDs particularly susceptible to the spread of fires due to their design, observers agree these are important areas on which to focus. This focus is particularly needed for the standard on egress, because there might be some misunderstanding about what constitutes compliance.

The egress standard is a double-edged sword for the ED, notes George Mills, MBA, FASCHE, CEM, CHFM, CHSP, a senior engineer with The Joint Commission. The good news is that most EDs are considered "suites" by The Joint Commission, he says. "As a suite, the egress corridor is considered an 'intervening room,' so the criteria we normally use for egress corridors do not apply," Mills says. "That's why in the ED, you can do patient care in what looks like a corridor." So, for example, if you walk through this intervening room, he explains, you might see several triage bays on one side, with sliding door for entry. "That is not compliant in a normal patient care unit, but in a suite, it's OK," says Mills.

The 8-foot-wide clearance requirement also does not apply, he says. "If you have a Pyxis machine or a food cart in that area, it's OK. The only thing we ask is a requirement to maintain a 3-foot path of egress, so you can always get out of the area from all the different rooms," says Mills. Normally in the ED, most of these things are kept to one side of the space to provide a path of egress, he says.

The other requirement is that there must be two "separate and remote" doors in and out of the suite. "Most EDs are shaped in a horseshoe, so the two ways to get out are separate and remote from each other," Mills says.

Where EDs can run afoul of the standard, he warns, is when they arrange to have patients boarded in hallways (in other departments) to manage patient flow. "It's not compliant to be treating patients in hallways, say, in the med/surg area, because you have corridor clutter," says Mills. "If you have a separate observation area, then that's egress to an intervening room, but if you push them out of the ED early and board your patients in the hallways [in other departments], you have to be aware that's a violation."

The only exception is in an emergency situation, says Kathy John, MSA, ARN, CHSP, CHEP, chairwoman of the Atlanta Metropolitan Medical Response Healthcare Section. "If they activate their surge capacity plan, it's just like converting other spaces such as outpatient spaces, auditoriums, and conference rooms to short-term usage for surge capacity," John says.

Mills concurs. "If there is a surge situation, you have no options," he says. "If you have to board patients upstairs as part of surge response, that's acceptable."

Some EDs aren't 'caught'

If boarding patients in other departments is a violation of Joint Commission standards, why are so many EDs doing it?

"They get around it because they haven't been caught," says Mike McEvoy, PhD, REMT-P, RN, CCRN, EMS coordinator, Saratoga County, NY.

"Here's the problem: What The Joint Commission is telling you is that there are two different standards, and they do not treat the ED as a 'floor,' but it's important for ED directors to know that what's perfectly acceptable for them is not acceptable when a person goes to a floor," McEvoy says.

It's quite natural for ED managers to reason that if it's OK to do it in their department, it must be OK to do it upstairs in another department, he says. "Unfortunately, they don't think of the ED as being any different from the rest of the hospital, but if a Joint Commission person tells you it is, then, oh yeah — it is!" McEvoy says.

Probably the most important consideration when you think about egress and evacuation is that typically you evacuate "at the wall," he says. "So, keep in mind when you think about emergency planning to remove the curtains from your 'picture' of your department and use the walls as borders beyond which you have to move everybody," McEvoy advises.