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Who determines "self-preservation"?

Sifu

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I have a submittal for some sort of plastic surgery office. I asked for a written description of the activities and what I received back indicates that procedures "require sedation", that patients are "safely sedated" and under the direct care of "a certified personnel who is there to ensure further safety". It is a less than 24-hr facility, and states that "all patients satisfy the discharge criteria to be released within 30 to 45 minutes". The quotes are from their letter. I called it an ambulatory care facility. Now they are challenging my designation.

So my question is this; who determines if someone is incapable of self-preservation? Is there some criteria, or list of drugs, or types of procedures? I have not directly done any sedation dentistry projects or ever had any sedation dental work so I am not sure how that plays in. (My understanding is that those patients are not considered incapable of self preservation.)

They are understandably frustrated and want to walk back their description but I would like to know a little more before I put it in front of the boss.
 

steveray

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If they are sedated, they are incapable.....I think it is four at a time for ambulatory, have them produce a letter to that affect, signed by the licensed doctor, and play through...
 

mtlogcabin

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[BG] INCAPABLE OF SELF-PRESERVATION. Persons who, because of age, physical limitations, mental limitations, chemical dependency or medical treatment, cannot respond as an individual to an emergency situation.
 

Sifu

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Do you have opinions on what "sedated" is. From Webster's:
Definition of sedation
1 : the inducing of a relaxed easy state especially by the use of sedatives
2 : a state resulting from or as if from sedation

I just called a dentist to blindly ask about what they do. I asked if at any point a patient was incapable of getting up and walking out during a fire. The response was that sometimes ABSOLUTELY. In his letter to me the owner says the closest analogy to his operation would be sedation dentistry.
 

Sifu

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[BG] INCAPABLE OF SELF-PRESERVATION. Persons who, because of age, physical limitations, mental limitations, chemical dependency or medical treatment, cannot respond as an individual to an emergency situation.
I get that definition, what I don't see is how I (or someone else) make that determination.
 

Sleepy

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For NFPA 101 (2018, or 2012) Ambulatory Healthcare is outpatient with four or more persons incapable of self preservation, simultaneously. I think you are correct that sedation would qualify, if there are four or more patients. An office that sedates less than four at a time would likely be a Business occupancy.

IBC has a similar language (2015, Section 422.1) which defines Ambulatory Care Facilities where "potential for four or more care recipients are to be incapable of self-preservation at any time."

NFPA has a slightly more useful definition of the incapable-of-self-preservation thing than IBC and clearly includes "Anesthesia that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others" (para. 6.1.6.1). I know you can't rely on NFPA when applying IBC, but it can provide some context.

It seems there is nothing wrong with the written description of the activities, they just need to clarify if they do so with fewer than four patients at a time.
 

mtlogcabin

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I get that definition, what I don't see is how I (or someone else) make that determination.
You make the determination and if they disagree make them prove it

Is there a medical gas room? Then get a list of the gases they will use. If there is nitrous oxide then the patients will be incapable of self preservation .
ask for a list of drugs used during dental procedures

Oral sedation dentistry is a medical procedure involving the administration of oral sedative drugs, generally to facilitate a dental procedure and reduce patients fear and anxiety related to the experience. Oral sedation is one of the available methods of conscious sedation dentistry, along with inhalation sedation (nitrous oxide) and conscious intravenous sedation.[1] Drugs which can be used for sedation include diazepam, triazolam, zaleplon, lorazepam, and hydroxyzine.[2]
 

Sleepy

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There may be a distinction between "sedation" and "anesthesia" that is significant here. Something described as "conscious sedation" doesn't seem to be "incapable of self-preservation.

Sifu, you may want to contact your state Department of Health. They likely deal with licensing of healthcare facilities and have to deal with occupancy (Healthcare vs. Ambulatory Healthcare vs. Business) all the time. They may have some specific guidance.
 

jar546

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The mere fact that there response was that they always have someone who is certified with them at all times means that they have to for health care facility licensing reasons along with common sense of course just helped your case. Enough is enough and I have witnessed a lot of ambulance calls to places like this when there were complications from their routine surgeries........... yep you are correct.
 

Sifu

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I have made the call, and in doing so provided them with the codes and definitions (should I really have to do that for an architect in this position????). It is up to them to convince me now, and if they can't then convince my boss. Sleepy, you have nailed the source of my doubt and I will try to reach out to the health department. And, jar, you caught onto a significant point that drove this. If they are providing an anesthesiologist or RN for the direct care I think that tells me something.

"under the direct care of myself, a certified anesthesia personnel (who is there to ensure further safety, not because of the depth of anesthesia), and registered nurses."
 

ICE

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Four is a relatively large number when counting the people that might be anesthetized at a given time. At most dental practices the number one is more likely.
 

mark handler

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You cannot tell how a sedative will work on people.
Everyone reacts differently to drugs.
If they administer a sedative drug calm someone down, that could make them lethargic or fall asleep, and become "incapable of self-preservation".

As a building official you need to make that call. and it could kill someone.
That's why you err on the side of caution.
 

Sifu

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You cannot tell how a sedative will work on people.
Everyone reacts differently to drugs.
If they administer a sedative drug calm someone down, that could make them lethargic or fall asleep, and become "incapable of self-preservation".

As a building official you need to make that call. and it could kill someone.
That's why you err on the side of caution.
Agree, thats what I am doing. I am just looking for more information in case I can avoid having to err on any side. It would be much better if I can find some definitive criteria but alas, like many other issues, finding the black and white may prove difficult.
 

RLGA

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Agree, thats what I am doing. I am just looking for more information in case I can avoid having to err on any side. It would be much better if I can find some definitive criteria but alas, like many other issues, finding the black and white may prove difficult.
There is a difference between sedation, general anesthesia, and regional (localized) anesthesia. Sedation is a drug-induced state of calm or sleepiness and may not involve complete unconsciousness (moderate sedation). General anesthesia involves a total loss of consciousness.

42 CFR 482.52(a) establishes the requirements for providing anesthesia services (which includes sedation), and it states that anesthesia can only be administered by an anesthesiologist; an MD or DO; a dentist, oral surgeon, or podiatrist; a certified registered nurse anesthetist (CRNA), or an anesthesiologist's assistant that meets specific requirements and is under the supervision of an anesthesiologist. If sedation is the only method used, then an anesthesiologist may not be on staff, but other qualified personnel may be allowed to administer the surgical sedative. Per the American Society of Anesthesiologists, moderate sedation can be administered by a "nonanesthesiologist practitioner," which per the CFR would be an MD, DO, dentist, oral surgeon, or podiatrist. A "supervised sedation professional" can also administer a sedative and monitor patients during moderate sedation under the supervision of a nonanesthesiologist practitioner.

If the place has only one person that is qualified, then I would say that the threshold of four people incapable of self-preservation would not be met--someone qualified must be with a patient at all times when sedated (i.e., pre-procedure, during the procedure, and post-procedure). If there are four or more qualified people (or there are two or more procedure/surgery rooms in the building with two or more pre-/post-procedure rooms), then I would say there is a good chance that four or more patients may be incapable of self-preservation at one time.
 

mark handler

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Agree, thats what I am doing. I am just looking for more information in case I can avoid having to err on any side. It would be much better if I can find some definitive criteria but alas, like many other issues, finding the black and white may prove difficult.
The code does not cover every contingency.
Never has, never will.
Not intended to.
That's where the debate comes in on Knowledge vs Wisdom
Knowledge
is about facts and ideas that we acquire through study, research, investigation, observation, or experience. Wisdom is the ability to discern and judge which aspects of that knowledge are true, right, lasting, and applicable.
 

Sifu

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The four person limit isn't a concern. They will be classified as an ambulatory care facility by IBC definition even if they only have one at a time. The provision for separated construction kicks in after four people, but even if under four the classification remains. There are several issues with the proposed design, but they all fall in line behind the requirement for fire suppression in IBC 422.6. This is a non-suppressed building, which would prevent the project approval as an ambulatory care facility regardless of the number of patients. Other concerns such as EATD, CPET, exit separation, rated enclosures, corridor widths etc are present but irrelevant if they can't get past the suppression.

I did speak with the health-care licensure board/life safety official for the state. This facility is not a licensed surgical center under the state board. They (the bureau) do not have an established criteria for "incapable of self preservation", but in speaking with him he agreed this is likely the case. I am gonna leave it where it is. I am sure it will escalate but unless they can convince me otherwise I am staying where I am. But, I will continue the effort to gain knowledge about this, and hopefully develop some wisdom along the way. I often tell people that knowledge is the process of education, experience is the application of that knowledge, and wisdom is the combination of that knowledge and experience. I am pretty good at knowledge acquisition, and fairly well experienced (excepting this topic), wisdom..........meh. On this topic I lack the experience so the wisdom is lacking. That's why I asked the questions of all of you.
 

classicT

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upload_2018-12-28_12-1-52.png

In support of Sifu's comment above, the four or more criteria establishes the need for fire patitions.

Overall, I think you (Sifu) are on the right path. Do make sure that the occupancy type has been specified as a Group B, as ambulatory care facilities is specifically listed as such.
 

Sifu

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View attachment 3405

In support of Sifu's comment above, the four or more criteria establishes the need for fire patitions.

Overall, I think you (Sifu) are on the right path. Do make sure that the occupancy type has been specified as a Group B, as ambulatory care facilities is specifically listed as such.
That's kind of the heart of the matter. They want it to be a group B like a doctors office, but I say group B like an ambulatory care facility.
 

north star

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Oct 19, 2009
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* = * = *

Sifu,

In your review of the proposed Ambulatory Care Facility,
...when the patients will be "safely sedated", has the architect
included an alternate source of power in their design [ RE:
Article 517 in the NEC ] ?.......This "may" mean using battery
powered systems or a Generator.

FWIW, ...I agree with your interpretation.......As **Mark Handler**

has stated, every person is different and different forms of
sedation may effect someone differently, hence the need \
"requirement" to have certified personnel onsite.

Also,
" (should I really have to do that for an architect in this position????). "
Absolutely !.......IMO, this is part of your Due Diligence........You
are tasked to build a Code Case for your position........It is up
to them to prove you wrong !........You are the Legal Defense
Representative for all of their patients.


* = * = *
 
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