Classifying occupancy for outpatient clinics

A dental clinic has assistants who would help evacuate patients safely in case of an emergency. PHOTO COURTESY DR. NABIL NADJI, PERIODONTIST, RED DEER, ALTA.

Canada’s National Building Code (NBC) and related provincial codes are  occupancy-based, with classifications depending on potential fire load and risk. Each classification dictates the type of construction and structural fire protection requirements for a building based on its area, height, intended use and number of facing streets.

Classifying the occupancy correctly is therefore of significant consequence. Otherwise, the wrong code requirements could be applied, resulting in the insufficient provision of life-safety systems or the addition of unnecessary features.

In the absence of a scientific algorithm to classify a building (except for industrial occupancies), a certain amount of good judgment is warranted. The designer may use Appendix Note to Article 3.1.2.1. of Division B of NBC as a guide, but its list is not exhaustive.

The most crucial factor is a building’s principal use. A day-surgery clinic, by way of example, could be classified as a business and personal services occupancy (Group D) or a treatment occupancy (Group B, Division 2), based on the terms defined in the codes.

Defining patients’ use

The NBC does not permit sleeping and housing accommodations, treatment or personal care assistance or administering medicine or transient medical service in a business and personal services occupancy. Treatment occupancy, on the other hand, refers to the use of a building for the provision of medical or other health-related interventions, where overnight accommodation is available to facilitate that treatment and where the administration of these interventions may render outpatients incapable of evacuating to a safe location without the assistance of another person.

This definition was included in NBC 2010 with an encrypted, insinuative narrative to classify dentistry and day surgery procedure clinics as business and personal services occupancy. The National Fire Code (NFC) 2020 requires a fire emergency procedure to be provided where treatment is contained, but the above requirements do not restrict the number and type of patients permitted at any time, define day-surgery clinics, redefine treatment or revise the definition of business and personal services occupancy to incorporate the type of treatment permitted in a day-surgery clinic.

The prescriptions for both occupancies are foundationally different in the codes. The most obvious difference is the sizeable population of inpatients in a treatment occupancy who would require assistance to evacuate in case of an emergency. Since these people usually need additional time to evacuate a building, the quantity and quality of exits carry a greater significance. Where possible, many designers prefer to locate the required entrances and exits at the ground level.

Fire safety for day-surgery clinics

A day-surgery clinic provides services, surgeries (usually non-invasive) or medical procedures to outpatients who are not admitted for longer-term care, housing and overnight sleeping accommodations. These outpatients receive medical ‘treatment-service’ or observation and are subsequently discharged to go home or admitted to a hospital as inpatients. Operating rooms (ORs), recovery rooms, intensive care units (ICUs), birthing rooms and emergency wards, typically located in hospitals, are not permitted in outpatient clinics.

The number of outpatients in a day-surgery clinic should be limited based on the life safety systems deployed, as medical services might render a patient incapable of taking action for self-preservation. A day-surgery clinic must also have an adequate staff-to-client ratio.

Fire emergency procedures conforming to NFC 2020 are to be provided for every building where treatment is provided in business and personal services occupancies, irrespective of the number of outpatients, staff-to-client ratio and fire protection systems availability. The fire safety plan prescribes the identification, operation and maintenance of exit routes, exits, obstructions (like snow) in the evacuation route, exit signs, emergency lighting, fire-alarm systems and any other services required for the safe evacuation of patients and residents. It provides a safe and orderly evacuation under emergency situations, but has no direct perceptible impact on the additional time required for patients incapable of self-preservation.

Dental and dialysis clinics

The above context makes it feasible to classify a day-surgery clinic as a business and personal services occupancy if the pre-established maximum number of patients who might be rendered incapable of self-preservation complements the available life safety features. However, the current editions of NBC and NFC do not specify a maximum number of outpatients permitted under such occupancy classification.

Day surgery or medical service in a dental clinic, for example, may involve administering sedative drugs. The intent is to achieve unconsciousness or near-unconsciousness, but not to knock out the patient. A dental clinic has assistants who would help evacuate patients safely in case of an emergency. (More complicated procedures are usually performed in a hospital.)

Dialysis, meanwhile, is a treatment for kidney failure that clears the body of unwanted toxins, waste products and excess fluids. The patient’s blood is circulated through a dialysis machine and cleaned before being returned to the patient’s body. During an emergency, this procedure can be paused, providing an opportunity for staff to move patients to a safer location.

Dialysis treatment is not surgery, but a procedure during which patients remain relaxed and vigilant of their surroundings. Therefore, a dialysis clinic could be classified as a business and personal services occupancy.

However, patients are rendered incapable of self-preservation due to the insertion of needles in their arms. Dedicated staff would need to pause the dialysis machine and remove the needles in an emergency.

NFC 2020 vs. NFPA 101

NFC 2020 accepts a treatment area in a business and personal services occupancy without restricting the number and type of patients permitted in it.  The National Fire Protection Association (NFPA) 101 Life Safety Code, on the other hand, permits dentist offices, emergency care clinics, dialysis clinics and ambulatory outpatient clinics to be classified as business occupancies or ambulatory health care facilities, provided they meet both of the following conditions: (a) they are not intended to provide services or treatment simultaneously to four or more outpatients who are incapable of self-preservation; and (b) they are separated from health-care occupancy by construction with a minimum two-hour fire-resistance rating and the primary intent of the business occupancy classification is to provide services for the outpatient.

Table 1 on page 19 illustrates the startling difference between the life safety system features in a business and personal service occupancy containing a treatment area versus a business occupancy used as an ambulatory health-care facility.

Unproportional disconnect

Contrary to NFPA 101, NBC does not specifically prescribe life-safety guards for day-surgery clinics, whereas all the evidential explanations demonstrated in Table 1 unequivocally confirm permitting a treatment area in a business and personal services occupancy, without an organic mechanism of protecting patients rendered incapable of self-preservation, may lead to serious life-safety, financial and legal consequences.

Prescription of a fire safety plan in NFC compared to NFPA is not sufficient to compensate for the adequate features required for the safe evacuation of patients rendered incapable of self-preservation.

Classifying a building containing a treatment area as a business and service occupancy without noting the number, type and ratio of patients, along with the quantity and quality of exits, may well compromise the safety of outpatients. Failure to provide conclusive requirements for a day-surgery/outpatient clinic may result in a subjective, inconsistent and discretionary approach.

Authority having jurisdictions (AHJs) permitting a building containing ‘treatment-services’ as business and personal services occupancy might therefore recommend (a) limiting the number of patients incapable of self-preservation without assistance and (b) installing the minimum life-safety provisions listed in NFPA 101.

Avinash Gupta, P.Eng., is chief code compliance engineer and assistant fire marshal for the government of the Northwest Territories. Mohamed S. Mohamed, P.Eng., is East Canada manager for Jensen Hughes. Dominic Esposito, P.Eng., is a senior project consultant for Jensen Hughes. For more information, contact Gupta at avinashguptap.eng@gmail.com.