The latest guidance for damper testing in healthcare and hospitals has been awaiting final publication since 2014. It was published in May this year and you can download a copy here.
The document re-iterates that all healthcare organisations must have:
- A full inventory of ALL fire and smoke dampers within their premises
- This must include a set of plans showing the location of all dampers
- And, there must be access to every damper.
It is evident from our experience within healthcare buildings, that rarely are all three requirements met.
The document also reinforces that all dampers within hospitals should, by now, have been subject to a maintenance regime and, if not, then a complete check and test of ALL fire/smoke dampers must be undertaken.
Again, my experience is we regularly find dampers in hospitals which have never been tested since installation. This is evidenced by some being completely inaccessible due to other services and access restrictions.
However, the key point from the guidance which has confused me, is how the guidance draws a distinction on damper testing frequencies between critical and non-critical areas.
For those who are unfamiliar with medical facility maintenance, critical areas in hospitals are precisely defined in HTM-03-01 as:
- Operating theatres of any type
- Patient isolation facilities
- Critical, intensive care and high dependency units
- Neonatal units
- Category 3 & 4 laboratory rooms
- Pharmacy aseptic suite
- Sterile room inspection and packing areas
- MRI, CAT and related areas
- Any area with local exhaust ventilation (LEV) system
- Any other area which can be deemed as critical area.
In my opinion, the distinction within the guidance between critical and non-critical areas is the most confusing part of the HTM guidance.
It recommends annual testing of dampers in critical areas, but less frequent testing or testing of a partial number of dampers annually in non-critical areas.
Dust accumulation is believed to negatively impact the operation of fire dampers and therefore is a key factor in the risk assessment which drives the frequency of testing.
My understanding is that hospitals are perceived to have lower dust accumulations compared to non-healthcare buildings. This likely stems from their ‘high risk’ status and belief that ductwork is regularly cleaned. However, from my experience hospitals often have the least well maintained and dirtiest ductwork systems of any building type.
There are a small number of hospitals which have immaculately cleaned ductwork but for many, if any of the ductwork systems are cleaned regularly, it is often just those serving the operating theatres/intensive care and other critical areas.
I think that based on the list of critical areas and my knowledge of hospital ductwork cleaning, the frequency of testing may be the wrong way round for critical and non-critical areas.
The HTM document aims to have a risk-based approach. Unless deposit thickness testing of ductwork in non-critical areas is undertaken and proves the ductwork to be clean. I think dampers serving critical areas may sensibly be assessed under risk assessment and tested outside of annual frequency, but non-critical dampers should be tested annually.
I appreciate that each hospital currently makes an assessment with their risk management group and competent person but I sense that hospitals should primarily be assessing contamination / dust levels within systems first, to properly assess correct frequency of damper testing and I don’t believe this is currently the standard protocol when making their assessment.
Surely hospitals would be better served in having cheap deposit thickness testing undertaken within their ductwork systems. The results will give factual data on dust levels which can then form the basis for their decision of damper testing frequencies.
I appreciate there is a balance between providing a compliant solution and not wasting funds, but I believe this approach could in fact save money for Hospital Estates Directors.
This article was originally published on LinkedIn.
