Current through Reg. 49, No. 38; September 20, 2024
(a) An ambulatory surgical center (ASC) shall
comply with the requirements of this section for handling and storage of gases,
anesthetics, and flammable liquids. The ASC premises shall be kept free from
accumulations of combustible materials not necessary for immediate operation of
the facility.
(b) Flammable
germicides. If flammable germicides, including alcohol-based products, are used
for preoperative surgical skin preparation, the facility shall:
(1) use only self-contained, single-use,
pre-measured applicators to apply the surgical skin preparations;
(2) follow all manufacturer product safety
warnings and guidelines;
(3)
develop, implement, and enforce written policies and procedures outlining the
safety precautions required related to the use of the products, which, at a
minimum, shall include minimum drying times, prevention and management of
product pooling, parameters related to draping and the use of ignition sources,
staff responsibilities related to ensuring safe use of the product, and
documentation requirements sufficient to evaluate compliance with the written
policies and procedures;
(4) ensure
that all staff working in the surgical environment where flammable surgical
skin preparation products are in use have received training on product safety
and the facility policies and procedures related to the use of the
product;
(5) develop, implement and
enforce an interdisciplinary team process for the investigation and analysis of
all surgical suite fires and alleged violations of the policies; and
(6) provide a written report of all
occurrences of surgical suite fires within two business days to the department
in care of the facility licensing group, and complete an investigation of the
occurrence and develop and implement a corrective action plan within 30
days.
(c) Flammable and
nonflammable gases and liquids. Flammability of liquids and gases shall be
determined by National Fire Protection Association 329, Handling Releases of
Flammable and Combustible Liquids and Gases, 2002 Edition. All documents
published by National Fire Protection Association (NFPA) as referenced in this
section may be obtained by writing or calling the NFPA at the following address
or telephone number: National Fire Protection Association, 1 Batterymarch Park,
Quincy, Massachusetts 02269-9101 or (800) 344-3555.
(1) Nonflammable gases (examples include, but
are not limited to, oxygen and nitrous oxide) shall be stored and distributed
in accordance with Chapter 5 of the National Fire Protection Association 99,
Standard for Health Care Facilities, 2002 Edition (NFPA 99).
(A) Medical gases and liquefied medical gases
shall be handled in accordance with the requirements of NFPA 99, Chapter
9.
(B) Oxygen shall be administered
in accordance with NFPA 99, §9.6.
(2) Piped flammable gas systems intended for
use in laboratories and piping systems for fuel gases shall comply with
requirements of NFPA 99, §11.11.
(3) Flammable gases shall be stored in
accordance with NFPA 99, §11.10.
(4) Flammable and combustible liquids used in
laboratories shall be handled and stored in accordance with NFPA 99,
§11.7, and National Fire Protection Association 101, Life Safety Code,
2003 Edition, §20.3.2.2.
(5)
Other flammable agents shall be stored in accordance with NFPA 99, Chapter 7,
Materials.
(d)
Alcohol-based hand rubs. Alcohol-based hand rubs (ABHRs) are considered
flammable. When used, the ABHRs shall meet the following requirements.
(1) The dispensers may be installed in a
corridor so long as the corridor width is six feet or greater. The dispensers
shall be installed at least four feet apart.
(2) The maximum individual dispenser fluid
capacity is 1.2 liters for dispensers in rooms, corridors, and areas open to
corridors, and 2.0 liters for dispensers in suites of rooms.
(3) The dispensers shall not be installed
over or directly adjacent to electrical outlets and switches.
(4) Dispensers installed directly over
carpeted surfaces shall be permitted only in sprinklered smoke
compartments.
(5) Each smoke
compartment may contain a maximum aggregate of 10 gallons of ABHR solution in
dispensers and a maximum of five gallons in storage.
(e) Gasoline and gasoline powered equipment.
No motor vehicles including gasoline powered standby generators or any amount
of gasoline shall be located within the ASC building. Other devices which may
cause or communicate fire, and which are not necessary for patient treatment or
care, shall not be stored within the ASC building. All such devices and
materials when necessary shall be used within the building only with
precautions ensuring a reasonable degree of safety from fire.
(f) Gas fired appliances. The installation,
use, and maintenance of gas fired appliances and gas piping installations shall
comply with the National Fire Protection Association 54, National Fuel Gas
Code, 2002 Edition. The use of portable gas heaters and unvented open flame
heaters is specifically prohibited.
