The ASHE Annual Conference's yearly codes and standards plenary session was given a new look Tuesday, with Chad E. Beebe, AIA, CHFM, CFPS, CBO, SASHE, director, codes and standards, ASHE, taking the stage as moderator with a sole goal of answering the questions top-of-mind for attendees.

Fielding audience and online participant questions were panelists David A. Dagenais, BS, CHSP, CHFM, FASHE, director of plant operations and security, Wentworth Douglass Hospital; David Stymiest, PE, CHFM, FASHE, senior consultant, Smith Seckman Reid Inc.; Frank Van Overmeiren, president, FP&C Consultants Inc.; Susan McLaughlin, MBA, FASHE, CHFM, CHSP, managing director, MSL, Healthcare Consulting Inc.; and William E. Koffel, PE, FSFPE, president, Koffel Associates Inc.

With the session’s tag line “Just Ask,” attendees did just that, primarily focusing on the NFPA 99: Health Care Facilities Code.

One audience member questioned NFPA 99’s requirements for humidity in an operating room setting. Dagenais says that while there is no low-end requirement, facility managers must find a way to monitor humidity levels, either to watch it in real time or have a process in the OR where humidity levels are documented regularly.

“We as the healthcare facility professionals have to be able to answer, 'How do we get the humidity levels where they need to be during procedures?’” he says.

McLaughlin added that a building automation system would be the best way to go as opposed to having staff record humidity levels once a day. “There’s always human error and invariably there are holes in the log,” she says.

Another attendee queried whether ORs are considered wet locations according to NFPA 99. Degenais says that they are not, so long as a risk assessment is done confirming so. If a risk assessment is not done, then the code would call for the assumption that the OR is a wet procedure location.

While the industry has been doing risk assessments for years, the formal process mandated by code is one Degenais says is still “uncharted territory.” What should be assessed is the following:

  • If we lose the system/equipment, will it cause serious injury or death? (Category 1)
  • If we lose the system/equipment, will it cause minor injury? (Category 2)
  • If we lose the system/equipment, will it cause no injury but patient discomfort? (Category 3)
  • If we lose the system/equipment, will it have no effect on patients? (Category 4)

ASHE offers a tool for risk assessments, as do other organizations, to help facilitate the process. And Degenais advised that facility mangers also involve clinicians, physicians, and nurses to measure the level of risk involved.

Another hot topic was brought up regarding Legionella and requirements for testing for its presence.

“There aren’t any,” McClaughlin says.

The Centers for Disease Control and Prevention isn’t mandating that facilities be proactive in taking cultures, simply because if they do it will be found and then need resolved. Whereas the expectation is rather that facilities be prepared for a true outbreak.

“The expectation is you have a plan in place,” she says. “And that, of course, will include culturing.”

There is no mandated procedure for an outbreak scenario, either, as there are a number of ways to go about reacting to the issue, but none are perfect, McLaughlin adds.

“Everything has its pros and cons,” she says.

ASHE is available to field more codes and standards questions from members at