# Who determines "self-preservation"?



## Sifu (Dec 27, 2018)

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.


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## RLGA (Dec 27, 2018)

Sifu, I think your designation is correct. If a person at any time is under sedation, then they are not capable of self-preservation.


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## steveray (Dec 27, 2018)

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...


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## mtlogcabin (Dec 27, 2018)

[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.


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## Sifu (Dec 27, 2018)

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.


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## Sifu (Dec 27, 2018)

mtlogcabin said:


> [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.


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## Sleepy (Dec 27, 2018)

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.


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## mtlogcabin (Dec 27, 2018)

Sifu said:


> 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]


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## Sleepy (Dec 27, 2018)

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.


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## jar546 (Dec 27, 2018)

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.


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## Sifu (Dec 28, 2018)

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."


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## ICE (Dec 28, 2018)

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.


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## mark handler (Dec 28, 2018)

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.


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## Sifu (Dec 28, 2018)

mark handler said:


> 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".
> 
> ...


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.


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## RLGA (Dec 28, 2018)

Sifu said:


> 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.


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## mark handler (Dec 28, 2018)

Sifu said:


> 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.


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## Sifu (Dec 28, 2018)

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.


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## classicT (Dec 28, 2018)

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.


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## Sifu (Dec 28, 2018)

Ty J. said:


> View attachment 3405
> 
> 
> In support of Sifu's comment above, the four or more criteria establishes the need for fire patitions.
> ...


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.


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## north star (Dec 28, 2018)

** = * = **

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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## Sleepy (Dec 29, 2018)

Sifu said:


> 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.



Note that 422.6 (IBC 2012) refers to 903.2.2 which only requires the sprinklers if there are four or more incapable of self-preservation, or one or more on any floor other than the level of exit discharge.  And the sprinkler system is not required throughout the whole building.


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## cda (Dec 29, 2018)

Not near NFPA 101

It may give some guidance


If they cannot get up readily and walk out,,


You might be sedated


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## Sifu (Dec 31, 2018)

Sleepy said:


> Note that 422.6 (IBC 2012) refers to 903.2.2 which only requires the sprinklers if there are four or more incapable of self-preservation, or one or more on any floor other than the level of exit discharge.  And the sprinkler system is not required throughout the whole building.



The proposed design is on the second floor of the 2 story building.  That would require sprinklers no matter the number of care recipients, and include the floor below.  So the entire building will end up being suppressed.

As for the rhetorical question about doing the architects job.  It was rhetorical since I know if they can't get there themselves I have to help them.  I guess I naively believe they should be able to get there themselves.


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## ADAguy (Jan 9, 2019)

"never" assume Sifu; your license is similar to a noose, the court is the gallows (smiling).
Did you ever ask your E & O carrier for an opinion?


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## ADAguy (Jan 9, 2019)

mark handler said:


> 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.



Nice comment MH, gets into the realm of Best Practice.


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## Sifu (Jan 9, 2019)

Boss got the call from the lawyer today.  They (plastic surgeon) now want to say they don't sedate people.  If boss wants to accept a revised letter, that contradicts the first letter, it is on him.


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## ADAguy (Jan 10, 2019)

Ah, "risk management", hope the doctors E & O carrier agrees.
"Painless" plastic surgery ?!


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## sergoodo (Jan 27, 2019)

_The general consensus is that the threshold for a patient who is *"incapable of self preservation" is the patient that cannot breath without assistance. *_


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## cda (Jan 27, 2019)

sergoodo said:


> _The general consensus is that the threshold for a patient who is *"incapable of self preservation" is the patient that cannot breath without assistance. *_




a person can be sedated, but still breath on their own, but not be able to move


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## mark handler (Jan 28, 2019)

The Joint Commission/*NFPA® Life Safety Book *for Health Care Organizations
http://www.jcrinc.com/assets/1/14/LSG13_Sample_Pages.pdf
“Incapable of self-preservation” means that the individual would not be able to get out of a building by him- or herself in case of fire.

*NOT *just "...cannot breath without assistance....?


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## Sifu (Jan 28, 2019)

The issue here is I have a DP and owner/operator who initially used words like sedated, 30-minute recovery and who use terms like under the direct care of while sedated, that after I said they sounded like they were incapable of self-preservation are disputing the finding.  Out of my hands now, bosses and lawyers can hash it out.  I made my observation, erred on the side of caution.


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## ADAguy (Jan 28, 2019)

Best to have done as you did (smiling)


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## sergoodo (Sep 17, 2020)

mark handler said:


> The Joint Commission/*NFPA® Life Safety Book *for Health Care Organizations
> http://www.jcrinc.com/assets/1/14/LSG13_Sample_Pages.pdf
> “Incapable of self-preservation” means that the individual would not be able to get out of a building by him- or herself in case of fire.
> 
> *NOT *just "...cannot breath without assistance....?



Yes, of course 'NOT'. Should of clarified the consensus is general for patients undergoing 'in office' procedure sedated by anesthesiologist . The same anesthesiologist who in a moment can un-sedate the individual to wide awake state to get out of the building. Anesthesiologist can also 'amp up' the said individual enough to run out of the building...then around the block a few times. 

This type sedation is typical for plastic, colorectal, etc surgeons with procedure rooms in their offices, just not the prettiest ambulatory self preservation everyone envisions.


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## Mark K (Sep 17, 2020)

This is a situation where the criteria and terminology in the code should be established by the medical experts.


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## tmurray (Sep 18, 2020)

sergoodo said:


> Yes, of course 'NOT'. Should of clarified the consensus is general for patients undergoing 'in office' procedure sedated by anesthesiologist . The same anesthesiologist who in a moment can un-sedate the individual to wide awake state to get out of the building. Anesthesiologist can also 'amp up' the said individual enough to run out of the building...then around the block a few times.
> 
> This type sedation is typical for plastic, colorectal, etc surgeons with procedure rooms in their offices, just not the prettiest ambulatory self preservation everyone envisions.


That sure sounds like that person is incapable of self-preservation and needs assistance to me.


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## jar546 (Sep 18, 2020)

Any update on this?


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## mtlogcabin (Sep 18, 2020)

Mark K said:


> This is a situation where the criteria and terminology in the code should be established by the medical experts.


I disagree and believe the definition is clear enough for the building code application and purposes. A simpler solution might be to require ambulatory care facilities to provide a list and description of the medical treatments provided similar to a fire suppression systems requirement for a list of commodities within a building so a proper design can be done. Then if the TV cameras ever show up at your office after an event asking how come you allowed this you will have a documented answer.
We need to be diligent and thorough when doing plan reviews, however we can't just call them liars when we believe we are being mislead down a certain path because an owner/designer wants follow their vision or path. 

[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.


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## Tim Mailloux (Sep 18, 2020)

as someone who recently had his wisdom teeth removed and was under some form of mild sedation during the procedure, there is no way in hell I was capable of self preservation. Even after I was awake and walking under my own power I had no clue what was going on or where I was. 

You should ask the doctor if he requires his patients under going a procedure to have someone there with them to drive them home. That will tell you a lot.


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## my250r11 (Sep 18, 2020)

Tim Mailloux said:


> as someone who recently had his wisdom teeth removed and was under some form of mild sedation during the procedure, there is no way in hell I was capable of self preservation. Even after I was awake and walking under my own power I had no clue what was going on or where I was.
> 
> You should ask the doctor if he requires his patients under going a procedure to have someone there with them to drive them home. That will tell you a lot.



ALWAYS SEEMS THEY MAKE THEM GO OUT THE BACK SO OTHER PATIENTS DON'T SEE THEM ALL DRUGGED UP!!


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## ADAguy (Sep 19, 2020)

Good discussion, IN CA clinics are not required to be reviewed by OSHPD (local BD can do so), an arch can submit plans but they better know what they are doing.


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